An audit by any entity is never pleasant. Some audits are just spot checks by a provider. Other audits can spell trouble. Recently, a client of mine contacted me “just to make sure” that the requested records were not anything to be worried about. Make no mistake, a 40-chart audit is never a spot check. Do you know the players in an audit? UPICS, RACs, MACs, BIU, FBI and OIG is an alphabet soup that is sure to give you indigestion! Anytime you are confronted by a request for chart reviews, it is best to consult our team of professional compliance consultants before you respond to the request. Keep in mind that you are on a time deadline. Procrastination is the thief of time! If you are dealing with an audit, give me a call at 217-433-2405 or send me an email.
Unified Program Integrity Contractors (UPICs)
A UPICs goal is always to find fraud. UPICs have the authority to stop payments, recoup money and refer providers to the OIG. While they are not paid a commission, they are paid performance bonuses. This is the most serious of the audits.
Medicare Recovery Auditors (RACs)
RACs perform post-payment audits. They can go back 3 years. Medicare pays a RAC a contingency fee based on the demand letter.
Medicare Administrative Contractors (MACs)
MACs perform functions on behalf of CMS. MACs deal largely with mistakes in billing instead of fraud. Fraud is left to the UPICs and RACs.
Benefit Integrity Unit
This group of individuals use claim and data analysis to thwart unnecessary medial payments. They conduct audits and extrapolation. This is one-step away from legal action. The BIU are to be considered the legal arm of the FBI.
Office of Inspector General (OIG)
The OIG is the police for any Federal program. They ensure the integrity of the program by investigation. They deal with programs such as Medicare, Medicaid, and Federal Employee BCBS such as postal workers. They do not make spot checks.
The Federal Bureau of Investigations (FBI)
The FBI is the police for Commercial program carriers such as Blue Cross, Aetna, United Health Care and others. They do not make spot checks.