Medicare’s Bloodhound in the Southeast: SGS gets the UPIC Auditing Contract

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If you are a provider in the Southeastern Jurisdiction of the Unified Program Integrity Contractor (UPIC) zone, which includes Alabama, Florida, Georgia, North Carolina, Puerto Rico, South Carolina, Tennessee, the U.S. Virgin Islands, Virginia and West Virginia, and have not heard of SafeGuard Services, LLC (SGS), thank your lucky stars! However, all providers and practice managers need to be keenly aware of SGS and their activities as the UPIC in the Southeast.

The UPIC program is The Centers of Medicare and Medicaid Services’ (CMS) most recent iteration of auditing for fraud, waste and abuse detection, deterrence and prevention. UPICs perform integrity related activities for Medicare Parts A, B, durable medical equipment (DME), home health and hospice (HH+H), Medicaid and the Medicare-Medicaid data match program (Medi-Medi). CMS awarded SGS the UPIC contract effective June 1, 2018, with full activation in Florida, Puerto Rico and the U.S. Virgin Islands in January of 2019.

SGS, as a UPIC, is responsible for investigations, auditing and referrals to law enforcement, as well as providing support to law enforcement. SGS is also responsible for coordination of benefits activities and dissemination of information to other Medicare contractors. SGS partners with IntegriGuard, LLC (IG) to perform medical record reviews, financial reviews and corrective action with providers. It is key to note that SGS does not replace the Medicare Administrative Contractors (MAC), but is specifically targeted on auditing for fraud and abuse in reimbursement and expenses.

Most recently, on March 29, 2019, SGS and all other UPICs were mandated to coordinate all investigations, findings and referrals through the Unified Case Management System (UCM). The UCM is a national database used to update CMS of all fraud, waste and abuse data analysis on projects, leads and investigations, and also allows UPICs to track administrative and law enforcement actions.

The following agencies/organizations have access to the UCM:

• UPICs;
• National Benefit Integrity Medicare Drug Integrity Contractor (NBI MEDIC);
• Railroad Retirement Board (RRB);
• CMS contractors (FPS, PIMAS, Acumen, IBM);
• MAC Medical Review Units associated with integrity reviews;
• CMS;
• FBI;
• DOJ;
• HHS/OIG; and
• Other federal and state partners seeking to address program integrity in health care programs.

What does this mean? If you get an audit notice from SGS, then all of these eyes are watching. Reimbursement compliance has never had higher stakes!

Stephen Bittinger, Esq. is a Member of Nexsen Pruet based in Charleston, South Carolina. Stephen is admitted in North Carolina, Ohio and the District of Columbia. He is not licensed to practice law in South Carolina. Stephen has a unique, national practice in health care reimbursement defense and litigation.