U.S. Department of Health and Human Services
Office of Inspector General 
UPICs Hold Promise To 
Enhance Program Integrity
Across Medicare and 
Medicaid, But Challenges
Remain 
Suzanne Murrin 
Deputy Inspector General for Evaluation and Inspections  
September 2022, OEI-03-20-00330   U.S. Department of Health and Human Services 
 
Office of Inspector General
Report in Brief
September 2022, OEI-03-20-00330 
Why OIG Did This Review UPICs Hold Promise To Enhance Program
Unified Program Integrity 
Integrity Across Medicare and Medicaid, But 
Contractors (UPICs) are the 
Centers for Medicare and  Challenges Remain 
Medicaid Services (CMSs) only 
What OIG Found
program integrity contractors  Key Takeaway 
In 2016, CMS began consolidating its  
that safeguard both the 
Although  UPICs hold promise  Medicare and Medicaid program 
Medicare fee-for-service (FFS)
for leveraging cross-program  integrity activities to enhance its ability 
and the Medicaid programs 
consolidation to strengthen   to detect and deter fraud, waste, and 
from fraud, waste, and abuse. 
oversight, improvements are  abuse across both programs. UPICs  
Combined, Medicare and 
needed to better combat  conducted substantially more Medicare 
Medicaid provided health care 
fraud, waste, and abuse  FFS program integrity work in 2019  
coverage to 139 million people 
particularly in Medicaid.  compared to that for Medicaid.  The 
at a cost of $1.5 trillion in 2020.  
UPICs also conducted only  minimal 
Given the cost and scope of 
activities related to Medicaid managed care, even though most Medicaid 
these Federal health care 
enrollees receive services through managed care.  Overall, UPICs conducted 
programs, it is essential that  
disproportionately fewer Medicaid activities compared to the levels of 
UPICs successfully detect and 
funding they received from CMS for Medicaid program integrity activities. 
deter fraud, waste, and abuse.   
  UPICs faced several challenges that could have contributed to the lower 
How OIG Did This Review  levels of program integrity activities in  Medicaid.  These challenges 
We requested and analyzed  included problems with  Medicaid data  availability and quality, and 
workload data related to  differences across States Medicaid policies and regulations.   
program integrity activities for 
We found wide unexplained disparities in program integrity activities 
each of the five UPICs in 2019.  
across UPICs, even after adjusting for  the size of their respective oversight 
In addition, we sent a survey to 
responsibilities.  Further, strategies that unify Medicare and Medicaid data 
each UPIC to ask about the  
to improve program integrity have not yet produced significant results.  
challenges it faced in 
performing these activities.   At the same time, CMS and UPICs have  laid a foundation for improvements.  
From CMS, we requested and  The development of collaborative processes, analytical tools, and  new 
reviewed certain deliverables  technologies across the UPICsincluding the Unified Case Management 
that  UPICs submitted related to  (UCM) system and Major Case Coordination (MCC) initiativehelps to  
their program integrity  achieve the benefits of unifying program integrity activities. Lastly, despite 
activities conducted in 2019.   challenges caused by the COVID-19 pandemic, UPICs were able to identify 
We also sent CMS a   vulnerabilities related to the pandemic and continue program integrity 
questionnaire asking about the  activities with some limitations.  
effects of the unification of 
What OIG Recommends and How the Agency Responded 
Medicare and Medicaid 
program integrity activities;  We recommend that CMS (1) implement a plan to increase UPICs Medicaid 
how CMS measures the  program integrity activities, particularly related to managed care; (2) make 
effectiveness of UPICs; and any  improvements to the UCM system; (3) implement a plan to help ensure the 
challenges UPICs face in  success of the MCC for Medicaid referrals; and (4) identify  the reasons for 
conducting their work.  We also  the unexplained variation in program integrity activities across  UPICs.  CMS  
asked both UPICs and CMS  concurred with all our recommendations.     
about the effects of the 
C OVID-19 pandemic on UPICs 
work.    
TABLE OF CONTENTS 
 
 
BACKGROUND................................................................................................................................................ 1  
FINDINGS......................................................................................................................................................... 9  
UPICs conducted substantially more program integrity activities for Medicare than for Medicaid ......... 9  
Although most people with Medicaid are enrolled in managed care, UPICs conducted minimal 
activities for managed care ................................................................................................................................................. 11  
Overall, UPICs face challenges in conducting Medicaid program integrity activities ...................................12  
Substantial disparities existed in the number of activities conducted across UPICs, even after adjusting 
for the size of their respective oversight responsibilities........................................................................................ 14  
Strategies to improve program integrity by unifying Medicare and Medicaid data did not produce 
significant results .................................................................................................................................................................... 15  
The introduction of new collaborative processes, systems, and analytical tools has laid the foundation 
for continued improvement in UPICs ability to conduct program integrity activities .................................17  
Despite challenges caused by the COVID-19 pandemic, UPICs were able to identify vulnerabilities 
related to the pandemic andwith some limitationscontinue program integrity activities .................19  
CONCLUSION AND RECOMMENDATIONS........................................................................................... 21  
Implement a plan to increase UPICs Medicaid program integrity activities, particularly related to 
managed care........................................................................................................................................................................... 22  
Make improvements to the Unified Case Management system ........................................................................... 22  
Implement a plan to help ensure the success of the Major Case Coordination initiative for Medicaid 
referrals....................................................................................................................................................................................... 22  
Identify the reasons for the unexplained variation in program integrity activities across UPICs .............22  
AGENCY COMMENTS AND OIG RESPONSE ........................................................................................ 24  
DETAILED METHODOLOGY ...................................................................................................................... 25  
APPENDICES................................................................................................................................................. 28  
Appendix A: Total Program Integrity Activities Conducted by UPICs in 2019 .................................................28  
Appendix B: Program Integrity Activities Conducted by UPICs for Medicaid Fee-for-Service and 
Medicaid Managed Care in 2019 ...................................................................................................................................... 31  
Appendix C: Agency Comments ........................................................................................................................................ 33  
ACKNOWLEDGMENTS AND CONTACT .................................................................................................37  
Acknowledgments.................................................................................................................................................................. 37  
   
Contact ........................................................................................................................................................................................ 37  
ABOUT THE OFFICE OF INSPECTOR GENERAL. ................................................................................... 38  
 
 
   
BACKGROUND 
OBJECTIVES 
1.   To determine the extent to which the Centers of Medicare & Medicaid 
Services (CMSs) unified program integrity contractors (UPICs) performed 
program integrity activities to identify fraud, waste, and abuse in 2019. 
2.   To identify the challenges that UPICs have encountered in conducting 
program integrity activities for both the Medicare and Medicaid programs.  
3.   To identify any benefits that resulted from unifying program integrity 
activities across Medicare and Medicaid. 
 
UPICs are the only program integrity contractors that safeguard both the Medicare 
fee-for-service (FFS) and Medicaid programs from fraud, waste, and abuse.  
Combined, Medicare and Medicaid provided health care coverage to 139 million 
people at a cost of $1.5 trillion in 2020.  Given the cost and scope of these Federal 
health care programs, it is essential that UPICs successfully detect and deter fraud, 
waste, and abuse. Unsuccessful efforts to safeguard program integrity leave Medicare 
and Medicaid financially vulnerable and puts enrollees health and welfare at risk.   
Over the past few decades, the Office of Inspector General (OIG) has produced a 
substantial portfolio of work that examined the fraud detection and investigation 
activities of previous program integrity contractors, found vulnerabilities in these 
contractors efforts to combat fraud and abuse, and made recommendations to 
reduce program vulnerabilities. This report is OIGs first evaluation of program 
integrity activities since the CMSs initiative to join Medicare and Medicaid program 
integrity activities under unified contractors.  
Background  
Unified Program Integrity Contractors 
In 2016, CMS began consolidating its program integrity contractors activities to 
enhance its ability to detect, prevent, and proactively deter fraud, waste, and abuse 
across the Medicare FFS (i.e., Medicare Part A and Medicare Part B) and Medicaid FFS 
and managed care programs. CMS stated it would achieve this by:  
   consolidating Medicare and Medicaid program integrity activities previously 
handled by separate contractors;  
   
UPICs Hold Promise To Enhance Program Integrity Across Medicare and Medicaid, But Challenges Remain     
OEI-03-20-00330  Background | 1     
   sharing and coordinating information among Medicare and Medicaid partners, 
such as Medicare contractors,  State Medicaid agencies,1 managed care
organizations (MCOs), and law enforcement; and  
   recommending administrative actions such as payment suspensions, civil 
monetary penalties, and exclusions in a timely manner.2    
UPICs operate in five geographic jurisdictions and integrate the functions previously 
performed by the Zone Program Integrity Contractors (ZPICs), Program Safeguard 
Contractors (PSCs), and Medicaid Integrity Contractors.  Since June 2018, a fully 
operational UPIC has covered each of the five jurisdictions shown in Exhibit 1.   
Exhibit 1.  UPIC jurisdictions and contractors 
 
 
 
 
 
 
 
 
 
 
 
 
Western UPIC (Qlarant Integrity Solutions)a      Northeastern UPIC (SafeGuard Services)b  
 
       
  Southwestern UPIC (Qlarant Integrity Solutions)     Southeastern UPIC (SafeGuard Services)b, c   
       
Mid-Western UPIC (CoventBridge)     
 
       
Source: CMS, Umbrella Statement of Work Appendices, Appendix B, p. 13, February 2020.  SafeGuard Services, LLC,  UPIC 
Locations.  Accessed at http://www.safeguard-servicesllc.com/Home/locations on March 4, 2020. 
a   The Western UPIC also covers American Samoa, Guam, and the Northern  Mariana Islands.  
b  The  Northeastern UPIC covers Medicare  Part B in Arlington County, Fairfax County, and the city  of  Alexandria  in 
Virginia; the Southeastern UPIC covers Medicare and Medicaid in all other areas of Virginia. 
c  The Southeastern UPIC also covers Puerto Rico and the Virgin Islands. 
_____________________________________________________________________________________________________________________________  
1 Throughout this report, we refer to State Medicaid agencies as States; we also include U.S. territories 
and the District of Columbia in the term States. 
2 CMS, UPIC Umbrella Statement of Work, April 2020,  1.1.  
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UPICs Funding 
In calendar year 2019, UPICs received $101 million in funding from CMS.  Each UPIC 
received between $16.5 million and $24.5 million in funding.  CMS determines UPIC 
funding on the basis of historical workload data and regularly evaluates and adjusts 
funding based on fluctuations in workload.  
Although the UPIC contract includes Medicare, Medi-Medi,3 and Medicaid  program 
integrity work, there is separate and distinct funding to conduct work for each of the 
three programs.  Each UPIC submits a Basis of Estimate to CMS that reflects how the 
UPIC anticipates allocating its resources, time, and workload across Medicare, 
Medicaid, and Medi-Medi activities.  CMS requires UPICs to track all costs incurred 
and bill them to the correct programs funding source (i.e., Medicare, Medicaid, or 
Medi-Medi).  CMS tracks UPICs use of funds by requiring each jurisdiction to submit 
a monthly cost report that summarizes costs for each of the three programs and 
includes a plan to correct any projected rate adjustments.  CMS expects UPICs time 
and resources spent across Medicare, Medicaid, and Medi-Medi to generate a 
positive return on investment. However, the UPICs are not required to directly align 
their output (e.g., investigations opened, cases referred, etc.) with the funding 
received. This is because CMS wants the UPICs to take the appropriate action based 
on the facts of each case.      
UPICs are also eligible for performance-based award fees.  CMS evaluates the UPICs 
on the basis of criteria in an award fee plan that links to CMSs goals of achieving 
enhanced detection and prevention of fraud, waste, and abuse across the Medicare 
and Medicaid programs. According to CMS, it determines award fees based on 
performance, quality, timeliness, and coordination between the UPICs and other 
program integrity contractors. 
UPICs Activities 
UPICs conduct a variety of required program integrity activitieswithin their assigned
jurisdictionsin accordance with the contractual requirements described in the UPIC 
Statement of Work created by CMS.  UPICs prioritize and screen leads to determine 
whether they merit an investigation, conduct investigations, perform data analysis, 
review medical records, recommend claims processing edits, identify overpayments 
for collection, and identify vulnerabilities. As a result of these activities, UPICs make 
referrals to law enforcement and identify the need for administrative actions such as 
payment suspensions, civil monetary penalties, and revocations.  In addition, UPICs 
provide support and education to various stakeholders, and support appeals related 
to Medicare and Medicaid administrative actions.4    
_____________________________________________________________________________________________________________________________  
3 The Medicare-Medicaid data match program (Medi-Medi) analyzes billing trends across the Medicare 
and Medicaid  programs.    
4 UPICs also may conduct Medicaid provider cost report audits.  
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UPICs are not the only entities conducting Medicaid program integrity activities.  
States dedicate resources to their Medicaid program integrity units and State 
Medicaid Fraud Control Units (MFCUs).  In addition, individual Medicaid managed 
care plans have Special Investigative Units (SIUs) to investigate potential fraud, waste, 
and abuse. 
Screening and Prioritizing Leads and Opening Investigations. UPICs partner
with CMS to identify and prioritize leadsi.e., suspected instances of fraud, waste, or 
abusefor investigation.  CMS instructs UPICs to screen and prioritize leads, 
identified proactively by the UPIC or from external sources such as law enforcement 
entities, that are likely to result in administrative actions.  From these prioritized leads, 
UPICs open and conduct investigations to determine the facts of each case as well as 
the magnitude of the alleged fraud. When the UPIC receives a lead specific to the 
Medicare or Medicaid program, the Statement of Work requires the UPIC to compare 
the lead with any available data to  determine whether a parallel issue exists in the 
other program. 
Performing Data Analysis Projects.  UPICs  Exhibit 2.  Data Analysis Sources  
plan and perform a range of data analysis projects and Tools Available to UPICs  
on Medicare and Medicaid claims and encounter  
data. These analyses support program integrity
activities by identifying patterns and trends of 
fraud, waste, and abuse. CMS directs UPICs to 
place high emphasis on data analysis activities
that lead to  effective investigations and 
successfully support administrative actions.  CMS 
expects UPICs to perform data analyses using 
the Fraud Prevention System (FPS), Integrated 
Data Repository (IDR), and One Program 
Integrity (One PI) portal. Exhibit 2 defines these 
sources and tools.  
Additionally, the Medi-Medi data matching 
program is an important component of UPICs 
data analysis activities.  States volunteer for the  Source: CMS, UPIC Umbrella Statement of Work, 
April 2020,  5.2.2 and 7.5.1.  
Medi-Medi data matching program, which 
generates a data set that analyzes billing trends across the Medicare and Medicaid 
programs to identify potential fraud, waste, and abuse.    
Identifying and Referring Overpayments.  UPICs may identify overpayments
made to providers that do not necessarily involve fraudulent intent during their 
analysis of Medicare and Medicaid  payments.  UPICs refer overpayments made to
providers to either Medicare Administrative Contractors or States for collection. 
Recommending Administrative Actions.   UPICs also may recommend 
administrative actions as a result of their program integrity activities.  Administrative  
actions include, but are not limited to, revoking certain providers Medicare 
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OEI-03-20-00330  Background | 4     
enrollment, terminating certain providers Medicaid enrollment, suspending payments 
to certain providers, and implementing civil monetary penalties.5 UPICs also support
the appeals process related to Medicare and Medicaid administrative actions such as 
claim determinations, overpayment determinations, payment suspensions, provider 
revocations, and provider terminations. 
Making Case Referrals.  UPICs make case referrals to various entities as a result of 
their program integrity activities. UPICs can refer cases of potential fraud, waste, or 
abuse to OIG, other law enforcement entities, CMS, or States.   
CMS established the Major Case Coordination (MCC) forum for both Medicare (April 
2018) and Medicaid (January 2020) to provide an opportunity for UPICs to discuss 
their top investigations with CMS and law enforcement.  The goal of the MCC process 
is to collaborate with all the MCC key decision makers and provide guidance on each 
investigation. 
Reviewing Medical Records.  UPICs conduct pre- and post-payment medical
reviews of medical records to identify, address, and reduce provider billing errors.  
UPIC medical review activities may include reopening claims and reviewing providers  
medical records to determine the appropriateness and medical necessity of services 
performed. On the basis of these medical reviews, UPICs recommend whether the 
claim should be or should have been paid or denied. 
Developing and Recommending Edits.  The results of UPICs data analyses can 
inform their development of edits for Medicare FFS claims processing systems and 
edit recommendations to States.  Edits are added to claims processing systems to 
evaluate claims submissions to ensure compliance with program requirements and 
identify and prevent inappropriate payments.   
Identifying Vulnerabilities.  The results of UPICs data analyses may identify 
program vulnerabilities.  A vulnerability is a flaw or weakness in policy and/or 
regulatory authority that increases the likelihood of Medicare or Medicaid making 
significant inappropriate payments to providers.  UPICs report these vulnerabilities to 
CMS along with suggested ways to address them.   
Supporting CMS, States, and Law Enforcement.  Given the broad scope of 
their review responsibilities, UPICs collaborate with and provide support to a variety 
of stakeholders. UPICs facilitate information sharing across Medicare and Medicaid, 
assist in others efforts to identify vulnerabilities, and streamline program integrity 
efforts across these entities to prevent of fraud, waste, and abuse.  UPICs support 
CMSs program integrity activities and collaborate with States and law enforcement 
agencies. UPICs support CMS by providing subject matter expertise and collaborating 
with CMS in its program integrity initiatives. UPICs are required to collaborate with
States to build an effective program integrity strategy to combat fraud, waste, and 
abuse. Further, UPICs collaborate with law enforcement entitiesincluding OIG, State 
_____________________________________________________________________________________________________________________________  
5 Administrative actions that UPICs recommend for Medicaid would be taken by the State.  The UPICs cannot 
suspend Medicaid payments or terminate Medicaid provider enrollment.  
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attorneys general, Medicaid Fraud Control Units, and the Department of Justiceby 
responding to law enforcement requests for information and assistance.  UPICs also 
educate Medicare Parts A and B and Medicaid providers and suppliers; States; 
Medicare Advantage plans; and Medicaid managed care entities about program 
integrity issues. 
UPIC Activities During the COVID-19 Pandemic.  In March 2020, CMS directed 
all program integrity contractors, including UPICs, to limit their program integrity 
activities following the declaration of a national emergency regarding the COVID-19 
pandemic.6   Specifically, CMS instructed UPICs to halt activity that involved any 
engagement with, communication with, or observation of  healthcare providers to 
ensure that providers could devote all resources to addressing the pandemic.  CMS 
revised this guidance in July 2020 and September 2020 to allow UPICs to resume 
program integrity activities under certain parameters and instructed UPICs to consult 
with States to obtain guidance on contacting providers to resume Medicaid program 
integrity efforts. 
UPICs Reporting Requirements 
UPICs submit to CMS a Monthly Status Report and a Quarterly Program 
Vulnerabilities Report to share the results of their efforts to safeguard Medicare and 
Medicaid from fraud, waste, and abuse.  The Monthly Status Report summarizes a 
UPICs monthly activities (e.g., the number of data analysis projects performed, 
investigations conducted, and overpayments referred for recovery).  The Quarterly
Program Vulnerabilities Report identifies program vulnerabilities and recommends 
corrective actions to address them.  UPICs also submit plans and reports regarding 
State and stakeholder education, data analysis projects, and assessments of particular 
program integrity activities. UPICs have access to the Unified Case Management 
(UCM) system, which CMS developed as a centralized repository for both Medicare 
and Medicaid leads and investigations.  CMS uses the UCM system to continuously 
monitor and evaluate UPIC performance. 
Related OIG Work 
A 2016 OIG report found variation in the level of benefit integrity activities conducted 
across contractors and years.7  OIG recommended that CMS examine the trends in 
workload statistics and determine whether they align with CMSs benefit integrity 
goals. We also recommended that CMS examine the variation in workload statistics 
among benefit integrity contractors and identify workload definitions that need to be 
clarified to ensure that contractors report data uniformly and in the way CMS intends.  
CMS concurred with our recommendations and established priorities which targeted 
its investigative focus on certain benefits.  CMS provided workload statistics that 
_____________________________________________________________________________________________________________________________  
6 CMS, Technical Direction Letter, PI-2020-0004, Operations During National Emergency, March 19, 2020. 
7 OIG, Medicare Benefit Integrity Contractors Activities in 2012 and 2013: A Data Compendium (OEI-03-
13-00620), May 2016. 
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demonstrated the results of CMSs new targeted focus.  CMS also updated its system 
that includes workload statistic definitions to be used by all contractors. 
Previous OIG work identified the shortcomings of Medicare and Medicaid program 
integrity contractors activities and data. For example, OIG found substantial variation
in (1) the number of investigations Medicare program integrity contractors started 
and (2) the number of cases that they referred to law enforcement.8 Further, OIG 
work identified substantial inaccuracies in contractors workload statistics9 and found 
that missing or inaccurate data compromised contractors ability to accurately 
perform data analysis.10  
Methodology 
Data Collection 
We began this evaluation during the COVID-19 pandemic.  Because the objectives of
this evaluation centered on the program integrity activities and results of the UPICs, 
we expected that if we selected a timeframe during the height of the pandemic, our 
results might not be indicative of the UPICs general efforts and results.  Therefore, we 
focused the analysis on program integrity activities conducted in 2019the most 
recent full year that preceded the pandemic. 
We requested workload data related to each of the five UPICs program integrity 
activities in 2019.  In addition, we sent a survey to each UPIC to ask about their 
experiences performing these activities, including any challenges.  From CMS, we  
requested and reviewed certain deliverables that UPICs submitted related to their 
program integrity activities conducted in 2019.  We also sent CMS a questionnaire 
asking about the effects of unification, how CMS measures the effectiveness of UPICs, 
and any challenges UPICs face when conducting their work.  We also asked both 
UPICs and CMS about the effects of the COVID-19 pandemic on UPICs work.   
We obtained 2019 Medicare FFS and Medicaid spending data for each UPIC 
jurisdiction.  CMS provided Medicare FFS spending data and we collected Medicaid 
spending data from the Transformed Medicaid Statistical Information System 
(T-MSIS).  T-MSIS is CMSs Medicaid data repository that contains information on 
enrollees, providers, claims, and managed care encounters.  
To collect information on OIGs experience with working with the UPICs, we also 
spoke with staff in OIGs Office of Investigations and Office of  Counsel to the 
Inspector General. 
_____________________________________________________________________________________________________________________________  
8 OIG, Medicares Program Safeguard Contractors: Activities to Detect and Deter Fraud and Abuse (OEI-03-
06-00010), July 2007. 
9 OIG, Zone Program Integrity Contractors Data Issues Hinder Effective Oversight (OEI-03-09-00520), 
November 2011. 
10 OIG, Early Assessment of Review Medicaid Program Integrity Contractors (OEI-05-10-00200), February 
2012. 
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Data Analysis 
To determine the extent of UPICs activities, we determined the total number of each 
program integrity activity conducted by each UPIC in 2019.  We then determined the  
number of these program integrity activities associated with Medicare, Medicaid, and 
Medi-Medi programs and compared the activities across the five UPICs.  We reviewed 
data on all of the UPICs activities, but the findings of this report do not include 
information on requests for information and assistance completed, medical reviews 
conducted, Medicare appeals handled, and compromised identification numbers 
identified.  While not presented in the findings, Appendix A does contain data about 
these activities. 
We additionally compared the number of program integrity activities conducted to 
each UPICs funding. To account for differences in the size of each UPICs oversight 
responsibility, we determined the number of program integrity activities for every 
$100 billion in Medicare and Medicaid spending in each jurisdiction and compared 
these numbers across the five UPICs. 
To identify the benefits of and challenges related to the unification of program 
integrity activities, we reviewed and analyzed the survey responses from CMS and 
UPICs. We also reviewed and analyzed responses related to the tools and strategies 
that UPICs use to detect fraud, waste, and abuse across programs as well as responses 
regarding the impact of the COVID-19 pandemic.  
Limitations 
We did not verify the information self-reported to us by the UPICs.  However, we 
followed up with the UPICs in cases in which we found inconsistent responses, data 
anomalies, or needed further clarification.  For the Medicaid spending data that we 
collected from T-MSIS, CMS notes that the quality of T-MSIS data can vary by State, 
by time period, and by area of analysis. 
Standards 
We conducted this study in accordance with the Quality Standards for Inspection and 
Evaluation issued by the Council of the Inspectors General on Integrity and Efficiency. 
 
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FINDINGS 
UPICs conducted substantially more program integrity activities 
for Medicare than for Medicaid  
UPICs 2019 Medicaid work lagged behind its Medicare work for all program integrity 
activities even though Medicaid spending exceeded Medicare FFS spending by 
$147 billion.11  These activities are important tools in safeguarding not only Medicare 
but also Medicaid programs from fraud, waste, and abuse.  Exhibit 3 highlights the
substantial differences in results between Medicare and Medicaid program integrity 
activities. Appendix A includes data that show similar results for UPICs additional 
program integrity activities. 
Exhibit 3.  UPICs performed substantially more Medicare program integrity
activities compared to those for  Medicaid.a, b  
Source: OIG analysis  of UPICs and CMSs responses to OIG request for information.  
a We added Medi-Medi program integrity activities to both the Medicare activities and Medicaid activities to account  
for the totality of activities conducted by  UPICs.  
b Administrative actions recommended represents the sum  of the revocations, exclusions, terminations, payment 
suspensions, and civil monetary penalties recommended by the UPICs.    
_____________________________________________________________________________________________________________________________  
11 Medicaid managed care spending includes both direct service dollars and MCOs administrative costs. 
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The percentage of program integrity activities conducted within 
Medicare, Medicaid, and Medi-Medi did not align with the 
funding UPICs received  
UPICs conducted disproportionately fewer Medicaid and Medi-Medi activities  
compared to the funding levels for those activities.  As shown in Exhibit 4, the UPICs  
overall activities did not align with the funding percentages received for Medicare, 
Medicaid, and Medi-Medi.  On average, UPICs funding for Medicare work accounted 
for 54 percent of their total funding, Medicaid accounted for 25 percent, and 
Medi-Medi accounted for the remaining 21 percent.  However, overall, Medicaid 
activities accounted for less than 25 percent of UPICs program integrity activities.  
Similarly, Medi-Medi activities accounted for less than 21 percent of UPICs results in 
all activities but data projects completed.  While CMS does not create benchmarks or  
goals for UPIC activities, CMS reported that it does expect UPICs to generate a 
positive return on investment with the funding they receive for each program.12    
Exhibit 4.  Program integrity activities conducted within Medicare, Medicaid, and 
Medi-Medi did not usually align with the funding that UPICs received. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Source: OIG analysis  of UPICs responses to OIG request for information and survey. 
  Note: Some totals may  not add to 100 percent due to rounding.   
_____________________________________________________________________________________________________________________________  
12 CMS stated that the UPICs are not required to directly align their outputs (e.g., investigations opened, 
cases referred, etc.) with the funding received. 
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Although most people with Medicaid are enrolled in managed 
care, UPICs conducted minimal activities for managed care 
Even though 83 percent of people with Medicaid received services through managed 
care in 2019, UPICs estimated that only 11 percent of their Medicaid activities focused 
on managed care.13 UPICs reported no data analysis projects completed or
vulnerabilities identified related to Medicaid managed care in 2019.  Further, they 
reported only a single Medicaid managed care referral.  Across the other program
integrity activities, UPICs conducted far more work in Medicaid FFS than managed 
care.14  UPICs screened nearly 20 times the number of Medicaid FFS leads (266 versus 
14) and opened 82 percent more investigations (238 versus 131) in 2019.     
Despite the minimal Medicaid managed care program integrity activities, each UPIC 
indicated that the level of Medicaid managed care work has increased since 2019.  
Although the split between Medicaid managed care work versus FFS work across UPIC 
jurisdictions was not reflective of the jurisdictions  proportion of Medicaid enrollees in 
managed care during the period under review, UPICs responded that improved 
relationships with the States, including more access to managed care data and the 
States willingness to allow UPICs to conduct work within Medicaid managed care, 
have contributed to an increase in Medicaid managed care work.   
UPICs did not track or report all activities related to Medicaid 
managed care 
CMS did not require UPICs to provide Medicaid  workload activities categorized by FFS 
and managed care in their Monthly Status Reports for 2019.  One UPIC could not 
distinguish FFS from managed care data for any of these five activities.  Three UPICs 
could not report the number of Medicaid data  analysis projects completed by FFS or 
managed care. Two UPICs could not report the number of investigations opened nor 
the cases referred by FFS or managed care.  When the UPICs could provide separate 
FFS and managed care data, there often were no activities reported for managed care.  
Appendix B contains the Medicaid FFS and Medicaid managed care activities data 
reported by the UPICs.  
As of 2021, some UPICs expanded the way they record Medicaid activities to 
distinguish FFS from Medicaid managed care.  Additionally, CMS now requires UPICs 
to identify whether Medicaid data projects, leads, investigations, referrals, appeals, 
and the outcomes of investigations are related to FFS or managed care. 
_____________________________________________________________________________________________________________________________  
13  The percentage of UPICs Medicaid work related to managed care ranged from 0 percent to 
34 percent. Four of the five UPICs reported that this percentage was an estimate.  
14 We requested and UPICs provided Medicaid  FFS and Medicaid managed care workload statistics for 
these program integrity activities: (1) data analysis projects completed, (2) leads screened,  
(3) investigations opened, (4) cases referred,  and (5) vulnerabilities identified.  
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Overall, UPICs face challenges in conducting Medicaid program 
integrity activities 
The quality and availability of Medicaid data limited UPICs 
Medicaid program integrity activities 
Both CMS and UPICs acknowledged that a lack of access to high-quality Medicaid 
data limited UPICs Medicaid program integrity activities.  One UPIC noted that delays 
in obtaining Medicaid data suitable for program integrity activities have stretched up 
to 1 year for some States, and in some cases, the data quality is so poor that analysis 
is not worthwhile. Another UPIC reported that States were reluctant to share data 
with UPICs because States felt the UPIC work was duplicative of work they could do 
on their own. In addition to these challenges, CMS responded that many States did 
not want to give UPICs direct access to their data because of concerns over previous 
security breaches within the States.  As a result, some States implemented additional 
security measures which contributed to the delays UPICs faced while beginning to 
work with States.  
UPICs reported that problems accessing Medicaid managed care data limited their 
ability to conduct program integrity activities related to managed care.  Because the 
T-MSIS Medicaid data was not approved for use in all States in 2019, one UPIC 
reported that it did not have access to any managed care data.  Others had to rely on
States or MCOs to provide them with managed care data, which can cause delays.  
Furthermore, even when UPICs received managed care data directly from States, there 
were problems with data quality.   
Access to T-MSIS data for all States has improved UPICs ability to 
conduct Medicaid program integrity activities, but problems remain.  All 
UPICs now have access to T-MSIS data for all States, which has alleviated some of the 
problems associated with accessing State Medicaid data.  In August 2021, CMS issued 
a Technical Direction Letter authorizing UPICs to use this data.15  Prior to this 
authorization and due to ongoing data quality validations, CMS did not permit UPICs 
to use T-MSIS data consistently to conduct program integrity activities in all States.  
UPICs noted that the uniformity of the T-MSIS data is helpful and reduces the need 
for UPICs to make ad-hoc data requests to States.  
Although T-MSIS data improved the UPICs ability to conduct program integrity 
activities, some UPICs did express issues with the quality and completeness of T-MSIS 
data. UPICs reported problems regarding T-MSIS data, such as missing enrollee and 
provider identification numbers; unusual dates and payment amounts; and missing 
claim status indicators.  One UPIC reported that the territories in its jurisdiction do not 
have a system to generate T-MSIS records and therefore they do not submit claims 
_____________________________________________________________________________________________________________________________  
15 CMS, Technical Direction Letter U-2021-0005, Availability and Use of Transformed Medicaid Statistical 
Information System (T-MSIS) Data for Program Integrity (PI) Purposes, August 19, 2021. 
UPICs Hold Promise To Enhance Program Integrity Across Medicare and Medicaid, But Challenges Remain     
OEI-03-20-00330  Findings | 12     
data to T-MSIS. Therefore, even with UPICs expanded access to T-MSIS, they may 
still need to request additional information from States and MCOs.  
A lack of Joint Operating Agreements (JOAs) with some States hindered 
UPICs ability to obtain Medicaid data.  Three UPICs reported that they do not 
have JOAs with at least one State in their jurisdictions, which limits their ability to  
conduct Medicaid program integrity activities in those States.   A JOA is meant to 
serve as an outline of the processes that will be used to create an effective working 
relationship between the UPIC and the State.  The UPIC Statement of Work from CMS  
requires UPICs to sign JOAs with each State in its jurisdictions.   
UPICs use not only T-MSIS data, but data provided by the State to perform analyses.  
Two UPICs reported that without a JOA, the UPIC cannot exchange data with a State.  
One UPIC noted that the lack of JOAs with two States in its jurisdiction prevented it 
from making ad-hoc data requests for Medicaid Management Information System 
data in those States.16  Another UPIC also did not have a JOA with one of the States in 
its jurisdiction as the State was not receptive to working with the UPIC to finalize the 
JOA. A third UPIC did not have a JOA with one State because the State questioned 
whether it was mandatory or voluntary to work  with the UPIC.  This UPIC also did not 
have a JOA  with a second State because that State wanted the UPIC to sign a 
contractwhich UPICs cannot doinstead of a JOA.   
UPICs may conduct fewer Medicaid investigations because they receive 
and screen fewer Medicaid leads.  Eighty-two percent of all leads screened by
UPICs in 2019 were for Medicare.  The UPICs opened 2,626 more Medicare 
investigations than for Medicaid in part because they received 3,368 more Medicare 
leads. According to one UPIC, external Medicaid leads must come from the States, 
and it receives very few Medicaid leads from the States.  Conversely, there are 
multiple sources of external leads related to Medicare, such as the Medicare phone 
hotlines, the Medicare Administrative Contractors, and FPS.  The potential for opening 
a larger number of Medicaid investigations could be realized if the number of leads 
received from other sources increased.  
The inability to duplicate program integrity projects across 
different States limits UPICs efficiency  
The structure of the Medicaid programs allows States to establish a wide variety of 
policies and procedures but also can complicate oversight activities because each 
States Medicaid program is unique. Differences in State policies, regulations, and 
organization mean that UPICs Medicaid program integrity activities can rarely be 
duplicated across States. All the UPICs reported that differences among State policies 
create challenges in investigating instances of potential Medicaid fraud and abuse.  
One UPIC reported that projects had to be tailored to each State because differences 
_____________________________________________________________________________________________________________________________  
16 The Medicaid Management Information System is an automated claims processing and information 
retrieval system that States must have to be eligible for Federal funding.  
UPICs Hold Promise To Enhance Program Integrity Across Medicare and Medicaid, But Challenges Remain     
OEI-03-20-00330  Findings | 13     
among States policies and regulations made the duplication of efforts difficult.  
According to another UPIC, one of its biggest challenges was designing and 
maintaining investigative processes that are compliant with States Medicaid 
processes, policies, and priorities.  One UPIC noted that reorganizations within some 
States programs sometimes made it difficult to determine whom to contact within 
the State.   
State restrictions and/or contractual requirements also can also hinder UPICs 
program integrity efforts. UPICs stated that these restrictions included limits on 
(1) the types of providers they are allowed to examine and (2) the timeframes they 
had to review claims. Two UPICs reported that differences in MCO contract language 
both within and between States creates challenges when conducting program 
integrity activities in Medicaid managed care.  UPICs also reported difficulties with the 
Medicaid overpayment identification and recovery process.  Three UPICs reported 
that some States in their jurisdiction prohibit the UPIC from identifying overpayments.  
Another UPIC noted that, in one State, MCOs have 1 year from the date of service to 
identify and recoup overpayments before the UPIC can seek out overpayments.  
Substantial disparities existed in the number of activities
conducted across UPICs, even after adjusting for the size of 
their respective oversight responsibilities 
Even after adjusting for jurisdictional oversight responsibility, certain UPICs conducted 
substantially more program integrity activities than their counterparts, especially 
investigations opened, cases referred, and data  analysis projects completed.  The UPIC 
that opened the most investigations opened three times as many investigations as 
the UPIC that opened the fewest investigations for every $100 billion in spending.  
Similarly, one UPIC referred more than twice the number of cases as another UPIC and 
one UPIC completed more than three times the number of data analysis projects as 
another. Exhibit 5 shows this variation for these three activities.  UPICs also varied in 
conducting other program integrity activities such as leads screened, administrative 
actions recommended, claims denied, vulnerabilities identified, and the value of 
overpayments they referred. 
CMS stated that it compares UPIC results across jurisdictions to assess UPICs 
effectiveness and to ensure consistency in measuring their performance.  However, 
the extreme variation in the level of all program integrity activities conducted by 
UPICs raises questions about why such substantial inconsistencies exist across 
contractors results. 
 
 
UPICs Hold Promise To Enhance Program Integrity Across Medicare and Medicaid, But Challenges Remain     
OEI-03-20-00330  Findings | 14     
Exhibit 5.  There were substantial disparities in the number of investigations  
opened, cases referred, and  data analysis projects completed by UPICs per
$100 billion in spending. 
 
 
 
 
 
 
 
 
 
 
Source: OIG analysis  of UPICs and  CMSs responses to OIG request for information  as well as analysis of T-MSIS data. 
Strategies to improve program integrity by unifying Medicare 
and Medicaid data did not produce significant results 
UPICs developed and employed strategiesstrategies that include both new 
approaches and leveraging established programs such as Medi-Medi data
matchingthat use both Medicaid and Medicare data to conduct analysis across 
programs. However, these strategies have yet to produce significant results.  When a 
UPIC receives a lead specific to the Medicare or Medicaid program, CMS requires the 
UPIC to review that lead against data from the other program to determine whether 
the issue exists there as well.  For States that choose to participate in the Medi-Medi 
data match program, UPICs also can perform proactive data analysis on integrated 
Medicaid and Medicare data sets.  By analyzing combined Medicare and Medicaid 
claims data, UPICs can detect problematic billing patterns that may not be evident 
when analyzing the data separately.   Although each of these efforts has produced 
some positive results, there are challenges that prevent the UPICs from maximizing 
their potential.    
All UPICs reported screening leads across both Medicare and 
Medicaid, but this cross-program review resulted in only a small 
percentage of new investigations  
Despite CMSs requirement that they review leads across both programs, UPICs 
estimated that on average only 1 percent of Medicare investigations and 2 percent of 
Medicaid investigations resulted from screening a lead that originated in the other 
UPICs Hold Promise To Enhance Program Integrity Across Medicare and Medicaid, But Challenges Remain     
OEI-03-20-00330  Findings | 15     
program.17  CMS requires UPICs to screen all leads against both Medicaid and 
Medicare claims and encounter data to determine if an issue identified in one 
program is occurring in the other. 
Although CMS reported that the consolidation of program integrity activities has 
provided increased awareness of fraudulent schemes in Medicare that could be 
occurring in Medicaid or vice versa and allows the UPICs to pursue these schemes in 
both programs, UPICs reported challenges in performing this cross-program work.  
UPICs reported that challenges with Medicaid data limit their abilities to effectively 
pursue schemes in both programs.  Three UPICs reported difficulties with performing 
follow-up of Medicare leads in Medicaid because of challenges in accessing Medicaid 
data. Another UPIC struggled to conduct cross-program work because of the poor 
quality and lateness of Medicaid data.  In addition to problems with the data, UPICs 
have faced challenges in consolidating activities because of the Medicare and 
Medicaid programs separate statutes, funding streams, and provider types.  For 
example, one UPIC reported that it cannot use a lead related to a Medicaid pharmacy 
to open a parallel lead in Medicare because the UPIC does not have oversight 
responsibility for the Medicare Part D pharmacy benefit.18   
UPICs conducted a limited number of Medi-Medi investigations  
Only 9 percent of investigations were related to the Medi-Medi program, despite 
21 percent of UPICs funding, on average, being allocated to Medi-Medi.  Under the 
Medi-Medi program, UPICs can use combined Medicare-Medicaid datasets to review 
billing trends across providers and service types and potentially identify outliers 
across both programs. For example, a UPIC may find that a provider has a normal 
billing pattern for a Medicare service, but upon adding their Medicaid billing for the
same type of service, that provider may become an outlier.   
UPICs ability to conduct proactive data analyses across both Medicare and Medicaid  
is limited, as 35 States chose not to participate in the Medi-Medi data match program 
in 2019. CMS prohibits UPICs from linking or matching Medicare and Medicaid data 
for States that do not participate in the Medi-Medi program, which limits UPICs 
ability to identify problems across both programs.  Increasing State participation in 
the Medi-Medi program may enhance the benefits of unifying program integrity 
activities and improve UPICs ability to identify potential vulnerabilities across both 
Medicaid and Medicare.  In July 2022, CMS reported that it is reimagining the 
Medi-Medi program, including how it uses Medi-Medi funding.  CMS stated that its 
_____________________________________________________________________________________________________________________________  
17 Four UPICs provided a specific percentage of investigations that resulted from screening a lead that 
originated in the other program.  The fifth UPIC reported less than one percent in their response. We 
excluded this response and calculated the average using only the specific percentages provided by the 
four UPICs. 
18 The UPICs coordinate with the Investigations Medicare Drug Integrity Contractor (I-MEDIC), a 
contractor that works to identify and prevent fraud,  waste, and abuse in Medicare Part D.   The UPICs can 
refer suspected cases of Part D fraud to the I-MEDIC.  Additionally, the UPICs and I-MEDIC have regularly 
scheduled monthly meetings to collaborate.  
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OEI-03-20-00330  Findings | 16     
goal is to is to extend the use of the Medi-Medi funding across all States, when 
appropriate. 
The introduction of new collaborative processes, systems, and 
analytical tools has laid the foundation for continued
improvement in UPICs ability to conduct program integrity 
activities   
CMS and UPICs report that the Major Case Coordination (MCC) 
initiative improved collaboration and increased the number and 
quality of Medicare referrals to law enforcement and has the 
potential to do the same in Medicaid 
Biweekly Medicare MCC meetings improved collaboration and increased 
the number and quality of Medicare referrals.  According to CMS, within a 
year of implementing the Medicare MCC there has been an over 200 percent increase 
in Medicare referrals to law enforcement.  Medicare MCC meetings allow CMS and 
law enforcement to evaluate each UPIC Medicare and Medi-Medi investigation for its 
quality, comprehensiveness, and appropriateness for referral.  According to CMS, it 
established the Medicare MCC as a partnership between law enforcement, UPICs, and 
all CMS components.  Since April 2018, UPICs have coordinated biweekly meetings 
that enable law enforcement and CMS to provide feedback to UPICs.   
Most UPICs stated that the collaboration among stakeholders is a benefit of the 
Medicare MCC. Both UPICs and investigators in OIG reported that this process has 
improved the relationship between OIG and the UPICs.  Investigators in OIG credited 
these meetings with increasing the quality of referrals they receive.  UPICs found that 
the Medicare MCC (1) ensured that the correct approach is used for each referral; (2) 
improved efficiency in conducting investigations, making referrals, and identifying 
overpayments; and (3) supported investigative activity for the purpose of 
recommending administrative actions.  Specifically, UPICs noted that the MCC had 
made their investigative strategy more targeted for law enforcement referrals. 
Four UPICs offered that the MCC initiative could be enhanced by:  
   making MCC meetings quarterly rather than biweekly, which would allow 
UPICs more time to investigate cases;  
   giving UPICs more than 1 week after MCC meetings to draft case referrals and 
administrative actions;   
   implementing a pre-MCC meeting to avoid jurisdictional overlaps with other 
UPICs; and 
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OEI-03-20-00330  Findings | 17     
   inviting representatives from the local and regional Federal Bureau of 
Investigation (FBI) offices to attend Medicare MCC meetings as this would 
allow UPICs to refer cases declined by OIG directly to the FBI during the 
meetings.  
Similarly, the Medicaid MCC initiative has shown potential to improve 
State and Federal collaboration regarding Medicaid referrals.  On the basis 
of the success of the Medicare MCC model, CMS implemented an MCC forum for 
Medicaid at the end of 2019.  The first Medicaid MCC meeting occurred in January 
2020. According to CMS, as of March 2021, Medicaid MCC meetings were held with 
6 States and law enforcement accepted 17 investigations for further review out of the 
33 investigations presented by UPICs. The Medicaid MCC participants include the 
State, State MFCUs, CMS, and OIG as well  as other law enforcement.  Thus, the 
Medicaid MCC takes into consideration the State-by-State nature of Medicaid.   
Regarding how to improve the Medicaid MCC initiative, one UPIC stated that better 
communication between stakeholders could improve the process.  Another UPIC 
suggested that States need to better understand the Medicaid MCC process and 
support the concept of the MCC.  
UPICs identified benefits of the Unified Case Management 
System (UCM), but note the need for additional improvements 
The UCM systemthe centralized repository for both Medicare and Medicaid 
investigationshas increased UPICs awareness of activities being conducted across 
jurisdictions. According to one UPIC, the UCM system enabled it to identify and 
coordinate actions with other contractors.  It also helped the UPIC ensure that there 
were no conflicts with other UPICs when developing data analysis projects.  One UPIC 
noted that the UCM system gave it the ability to see records across all UPICs.  
According to CMS, including all investigation documentation in one system also 
highlights any overlap between work in Medicare and Medicaid. 
Additional changes to the UCM system could improve UPICs oversight 
activities.  All five UPICs reported challenges with the UCMs reporting capabilities 
and suggested changes to the UCM system.  While UPICs are required to use the 
UCM, some note that the system does not capture all the information UPICs must 
track. This requires UPICs to continue to use additional tracking systems and 
databases to conduct their work. To meet CMS reporting requirements, and account 
for the data not included in UCM, some UPICs maintain their own internal tracking 
systems with information not captured by the UCM system.  According to two UPICs,
integrating the UCM system with other systems such as the Provider Enrollment, 
Chain, and Ownership System; FPS; the Recovery Audit Contractor data warehouse; 
and OnePI could improve efficiency and enhance analytic approaches.  To track 
concerns, one UPIC noted that the UCM system Helpdesk could be improved by 
shifting from an email helpdesk to a more integrated system.  A UPIC reported that it
was optimistic that CMSs work with a new contractor to improve UCM system 
UPICs Hold Promise To Enhance Program Integrity Across Medicare and Medicaid, But Challenges Remain     
OEI-03-20-00330  Findings | 18     
functionality and reporting would be successful, and another UPIC noted that 
solutions already implemented by this contractor have improved the systems 
functionality.  
UPICs reported that they have developed innovative analytical 
tools that improve their ability to detect fraud, waste, and abuse 
Four UPICs developed new information technology tools to conduct data analysis to 
detect fraud, waste, and abuse.  One of these tools has enhanced a UPICs ability to 
identify fraud trends, and three UPICs have developed tools to help prioritize high-risk 
investigations.  Additionally, three UPICs have developed software for predictive 
analysis and two UPICs developed artificial  intelligence software.  This software has 
enhanced UPICs capabilities of integrating social media and other types of data to 
find associations among suspect providers as well as uncovering fraud.  
Despite challenges caused by the COVID-19 pandemic, UPICs 
were able to identify vulnerabilities related to the pandemic 
andwith some limitationscontinue program integrity 
activities   
UPICs reported that the COVID-19 pandemic impacted their ability to conduct 
required program integrity activities in both the Medicare and Medicaid  programs.  
Beginning in March 2020, CMS restricted UPICs from communicating with or 
conducting onsite visits with healthcare providers and ordered UPICs to terminate 
prepayment reviews.  These limits were put in place to ensure that healthcare 
providers were able to devote their full resources to combatting the healthcare crisis 
at hand. CMSs directives affected the UPICs ability to request medical records and 
conduct provider interviews, which can delay work on open investigations.  In June 
2020, CMS revised its earlier directive by requiring UPICs to receive permission before 
engaging in previously restricted program integrity activities that could endanger the 
health and wellness of contractors staff and the community at large.   
Despite these challenges, each UPIC identified fraud, waste, and abuse related to the 
pandemic. UPICs diverted resources to permitted activities such as beneficiary 
interviews and reviewing the medical records they had received before the pandemic 
began. Some UPICs also conducted proactive data analysis to monitor schemes 
related to the pandemic.  UPICs reported identifying potential fraud, waste, and abuse 
connected to improper billing of COVID-19-related services, abuse of telehealth 
services, and abuse of Respiratory Panel Pathogen testing.  Similarly, CMS added
several pandemic topics as high-priority areas for program integrity work during 
calendar year 2021, such as COVID-19 testing and vaccinations.  The emphasis on 
COVID-19 within CMSs priority work areas highlights the continued threat the 
pandemic poses to program integrity. 
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OEI-03-20-00330  Findings | 19     
During the pandemic, CMS also requested that UPICs undertake new tasks.  CMS 
asked UPICs to validate certain high-risk DME suppliers that enrolled under a set of 
relaxed enrollment standards instituted during the pandemic. By granting waivers
and flexibilities during the pandemic,  CMS exempted providers from certain 
enrollment screening requirements including background checks, site visits, and 
accreditation requirements.  According to CMS, over 2,000 high-risk DME suppliers 
enrolled under these relaxed provisions.  In response, CMS instructed UPICs to 
validate DME suppliers enrollment, resulting in over 500 investigations and 
40 revocation referrals. 
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OEI-03-20-00330  Findings | 20     
CONCLUSION AND RECOMMENDATIONS 
UPICs hold promise for leveraging cross-program consolidation to strengthen 
oversight by employing new collaborative processes, analytical tools, and technology 
to conduct program integrity activities.  However, we identified several improvements 
needed to better combat fraud, waste, and abuseparticularly in the Medicaid 
program. The uniqueness of each States Medicaid program creates an inherent 
challenge for UPICs in conducting Medicaid oversighta challenge not present in 
conducting oversight of the more uniform Medicare program.  We found that UPICs 
ability to conduct robust Medicaid oversightparticularly in managed carewas 
limited due to poor data quality; lack of data access; and differences across State 
Medicaid laws, regulations, and MCO contracts.  These challenges resulted in UPICs 
conducting only limited program integrity work for Medicaid, especially Medicaid 
managed care, in 2019. The expansion of program integrity activities to include more 
Medicaid managed care, improvements in data systems, and further collaboration 
amongst UPICs and their stakeholders would increase the overall productivity of the 
UPICs and enhance their detection of fraud, waste, and abuse.  
UPICs are CMSs only program integrity contractor that safeguards both the Medicare 
FFS and the Medicaid programs from fraud, waste, and abuse.  Combined, Medicare 
and Medicare provided health care coverage to 139 million people at a cost of 
$1.5 trillion in 2020.  Given the cost and reach of these Federal health care programs, 
it is essential that UPICs successfully detect and deter fraud, waste, and abuse.  Our 
findings indicate that while CMS created a framework to improve program integrity in 
Medicare and Medicaid, improvements are needed to better combat fraud, waste, and 
abuse. 
The findings of this report provide further support for OIGs existing recommendation 
that CMS ensure that States reporting of national Medicaid data is complete, 
accurate, and timely.19  
Additionally, we recommend that CMS: 
_____________________________________________________________________________________________________________________________  
19  OIG, OIGs Top Unimplemented Recommendations: Solutions To Reduce Fraud, Waste, and Abuse in HHS 
Programs, October 2021. Specifically, Recommendation #13 is: CMS should ensure that States 
reporting of national Medicaid data is complete, accurate, and timely.   The relevant OIG reports related 
to this recommendation are National Review of Opioid Prescribing in Medicaid Is Not Yet Possible         
(OEI-05-18-00480); Weaknesses Exist In Medicaid Managed Care Organizations Efforts to Identify and 
Address Fraud and Abuse (OEI-02-15-00260); States Could Do More To Prevent Terminated Providers From 
Serving Medicaid Beneficiaries (OEI-03-19-00070); and Data on Medicaid Managed Care Payments to  
Providers Are Incomplete and  Inaccurate (OEI-02-19-00180).    
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OEI-03-20-00330  Conclusion and Recommendations | 21    
Implement a plan to increase UPICs Medicaid program integrity 
activities, particularly related to managed care  
CMS should identify and implement ways to enhance UPICs work in Medicaid, 
especially managed care. For example, CMS could: 
   require UPICs to conduct more data analysis projects with Medicaid managed 
care encounter data to generate more proactive leads, 
   work with UPICs to increase the use of Medicaid managed care encounter 
data in its Medi-Medi analyses,  
   work with States and UPICs to reduce program integrity limitations that UPICs 
encounter due to restrictive State requirements and/or MCO contractual 
language, and/or  
   continue to work with States that have yet to sign Joint Operating Agreements 
with the UPICs. 
Make improvements to the Unified Case Management system  
UPICs reported that additional changes to the UCM would assist with their program 
integrity activities. Therefore, CMS should obtain more detailed feedback from UPICs 
(either through the UCM Helpdesk or some other mechanism) on how the UCM can 
be improved. After receiving this feedback, CMS should then determine what 
improvements to implement.   
Implement a plan to help ensure the success of the Major Case
Coordination initiative for Medicaid referrals 
CMS has had success in improving the quality and number of Medicare referrals 
submitted by UPICs since the implementation of the Medicare MCC.  CMS should 
consider ways to ensure that the Medicaid MCC generates a similar level of success.  
To start, CMS could increase the number of Medicaid MCC meetings that are 
conducted. CMS also could seek out opportunities to provide States with education 
to better understand the Medicaid MCC initiative and how their active participation  
would benefit the States fraud detection activities.  
Identify the reasons for the unexplained variation in program 
integrity activities across UPICs 
Although there may be valid reasons for some variation among contractors, CMS 
should examine the substantial disparities in workload activities between UPICs that 
cannot be explained by their different levels of oversight responsibility or funding.  
We understand that certain geographical area across the country have historically had 
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OEI-03-20-00330  Conclusion and Recommendations | 22    
higher levels of fraud, but it is important for CMS to determine if this is the sole 
reason for these substantial disparities in UPIC activities or if there may be other 
possible reasons, including performance issues, that might be causing such extreme 
variation. 
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OEI-03-20-00330  Conclusion and Recommendations | 23    
AGENCY COMMENTS AND OIG RESPONSE 
CMS responded that UPICs are one piece of a complementary network of activities by 
both the States and Federal government to promote Medicaid program integrity.  As  
part of this network, CMS pointed to State Medicaid program integrity units, MFCUs, 
and Special Investigation Units within Medicaid managed care plans. CMS also noted 
that it promotes effective State fraud prevention activities through best practices, 
oversight reviews, and specialized training.  
Further, CMS stated that it has continued to work to refine and direct the UPIC work 
to where it is most effective.  Since OIGs review period, CMS noted that Medicaid 
managed care work has risen to represent about 50 percent of the current Medicaid 
UPIC caseload. 
CMS concurred with all of OIGs recommendations and has already taken action or 
has plans to take action for implementation.   
In response to our first recommendation on increasing UPICs Medicaid program 
integrity activities, CMS stated that its continuous improvement actions include 
activities focused on increasing the UPICs Medicaid managed care program integrity 
activities. In response to our second recommendation to improve the UCM system, 
CMS indicated that it has started to redesign the UCM system in close collaboration 
with the UPICs. In response to our third recommendation regarding the Major Case 
Coordination initiative, CMS stated that it will explore ways to maintain and enhance 
the initiative and educate States on how this collaboration can help them fight fraud.  
Finally, in response to our fourth recommendation on addressing unexplained 
variations across UPIC activities, CMS stated that it continuously monitors the 
program integrity activities performed across UPICs to ensure the optimal use of 
program integrity resources.  
OIG appreciates CMSs planned efforts to address our recommendations and looks 
forward to reviewing its actions when complete. 
For the full text of CMSs comments, see the Agency Comments appendix at the end 
of the report. 
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OEI-03-20-00330  Agency Comments and OIG Response | 24    
DETAILED METHODOLOGY 
Data Collection 
We began this evaluation during the COVID-19 pandemic.  Because the objectives of
this evaluation centered on the program integrity activities and results of the UPICs, 
we expected that if we selected a timeframe during the height of the pandemic, our 
results might not be indicative of the UPICs general efforts and results.  Therefore, we 
focused the analysis on program integrity activities conducted in 2019the most 
recent full year that preceded the pandemic. 
CMS Data.  From CMS, we obtained documentation on UPICs 2019 program 
integrity activities. This documentation includedfor each UPICworkload data 
from the Monthly Status Reports, Quarterly Vulnerability Reports, transition and 
implementation plans, data analysis strategies, education plans, and assessments of 
program integrity activities. 
We also surveyed CMS about the effects and challenges created by the unification of 
program integrity activities, CMSs oversight and assessment of UPICs work, and the 
effects of the COVID-19 pandemic on UPICs program integrity activities.  
UPIC Data.  From the UPICs, we obtained responses to an information request and 
survey about their program integrity activities.  In response to our information 
request, UPICs provided the number of specific program integrity activities conducted 
(workload data) in 2019 for each program (Medicare, Medicaid, and the Medi-Medi 
program). The requested data included the numbers of data analysis projects 
completed, investigations opened, cases referred, overpayments referred, and 
administrative actions recommended.   
In response to our survey, UPICs identified (1) the impact of unification on their 
program integrity activities; (2) their methods to access and use Medicare and 
Medicaid data for program integrity activities; (3) any challenges they face in 
conducting their program integrity activities; (4) their strategies for conducting 
program integrity activities during the COVID-19 pandemic; and (5) the tools and 
strategies they use to detect fraud, waste, and abuse.  
Spending Data.  From CMS, we obtained 2019 Medicare spending data for each 
UPIC jurisdiction. This included the amount of Medicare Part A and Medicare Part B 
spending.  
We obtained total Medicaid spending data for each State in 2019 from the T-MSIS 
data available on CMSs IDR.  To calculate total Medicaid spending for each State, we  
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OEI-03-20-00330  Detailed Methodology | 25    
added (1) the amount paid for all FFS claims  and (2) the amount of monthly capitation 
payments made to MCOs.20  We then summed spending for each UPIC jurisdiction.   
Data Analysis  
To determine the extent of UPICs activities, we reviewed and analyzed the 2019 
program integrity activities provided by UPICs.  For each UPIC, we determined the 
number of: 
   investigations opened;  
   referrals made; 
   administrative actions recommended (including revocations, exclusions, 
terminations, payment suspensions,  and civil monetary penalties 
recommended);  
   data analysis projects conducted;  
   leads screened; 
   value of overpayments referred;  
   medical review case requests conducted;  
   claims denied due to pre- and post-payment medical review;  
   savings associated with auto-deny edits; 
   Medicare appeals handled;  
   law enforcement requests for information and assistance completed;  
   compromised beneficiary and provider identification numbers identified; and  
   vulnerabilities identified.   
 
We then determined the number of these program integrity activities associated with 
Medicare, Medicaid, and Medi-Medi programs and compared the activities across the 
five UPICs.  We additionally compared the number of program integrity activities 
conducted to each UPICs funding. To account for differences in the size of each 
UPICs oversight responsibility, we determined the number of program integrity 
activities for every $100 billion in Medicare and Medicaid spending in each 
jurisdiction and compared these numbers across the five UPICs.  
To determine the benefits of and challenges to the unification of program integrity 
activities, we reviewed and analyzed the survey responses from CMS and UPICs.  We 
analyzed survey responses from CMS and UPICs to identify the benefits that were 
attributed to unifying program integrity activities as well as the challenges UPICs have 
encountered in performing program integrity duties during 2019 (prior to the 
COVID-19 pandemic).  We also reviewed and analyzed responses related to the tools 
and strategies that UPICs use to detect fraud, waste, and abuse across programs, 
including the use of technological tools. We then analyzed the survey responses from 
_____________________________________________________________________________________________________________________________  
20 Under managed care, a State pays an MCO a per-member, per-month feeknown as a capitation 
paymentfor each person enrolled with the MCO. The MCO then pays providers for all Medicaid 
services included in the MCOs contract with the State.   
UPICs Hold Promise To Enhance Program Integrity Across Medicare and Medicaid, But Challenges Remain     
OEI-03-20-00330  Detailed Methodology | 26    
CMS and UPICs describing the impact of the COVID-19 pandemic on UPICs program 
integrity activities during the pandemic. 
 
UPICs Hold Promise To Enhance Program Integrity Across Medicare and Medicaid, But Challenges Remain     
OEI-03-20-00330  Detailed Methodology | 27    
APPENDICES 
Appendix A: Total Program Integrity Activities Conducted by 
UPICs in 2019 
UPICs reported the number of program integrity activities they conducted in 2019.  If 
a UPIC was unable to provide the data requested, it responded with "Unable to 
determine" or "Did not track. 
Exhibit A-1.  Total program integrity activities conducted by each UPIC across Medicare, 
Medicaid, and Medi-Medi in 2019 
  Medicare   Medicaid   Medi-Medi   Total 
Data analysis  Northeast  66  22  37  125 
projects Southeast 43  14  4  61 
completeda  Midwest 31  20  15  66 
Southwest  66  35  34  135 
West  44  9  5  58 
Leads screeneda  Northeast  811  128  88  1,027  
Southeast  984  22  243  1,249  
Midwest  1,077   167  52  1,296  
Southwest  1,156   115  127  1,398  
West  1,252   158  78  1,488  
Investigations  Northeast  501  98  61  660 
openeda  Southeast 714  221  157  1,092  
Midwest 508  120  37  665 
Southwest  807  95  78  980 
West  693  63  30  786 
Vulnerabilities   Northeast  0  0  0  0 
identifieda  Southeast  0  0  0  0 
Midwest  0  0  0  0 
Southwest  9  0  0  9 
West  1  2  0  3 
Cases referreda  Northeast  125  5  30  160 
  Southeast  116  2  49  167 
Midwest  231  8  13  252 
Southwest  122  2  27  151 
West  70  16  11  97 
Value of  Northeast  $22,225,605   $305,261   $5,729,225   $28,260,091  
overpayments Southeast  $36,386,858   $4,075,597   $9,106,658   $49,569,113  
referred for  Midwest  $174,436,346   $3,178,395  $2,183,867   $179,798,608  
recoverya   Southwest  $65,883,281   $1,734,043   $8,143,572   $75,760,896  
West  $4,412,541   $9,398,846   $97,626   $13,909,013  
continued on next page  
 
UPICs Hold Promise To Enhance Program Integrity Across Medicare and Medicaid, But Challenges Remain     
OEI-03-20-00330  Appendix A | 28     
Exhibit A-1.  Total program integrity activities conducted by each UPIC across Medicare, 
Medicaid, and Medi-Medi in 2019 (continued) 
  Medicare   Medicaid   Medi-Medi   Total 
Total number of  Northeast  19,145   592  4,693   24,430  
prepay and Southeast  16,748   3,908   4,383   25,039  
postpay claims  Midwest 16,987   1,163   1,503   19,653  
denieda    Southwest 26,229   1,093   877  28,199  
West  4,170   98  1,851   6,119  
Total number of  Northeast  69  Did not track   9  78 
payment Southeast  70  0  18  88 
suspensions Midwest 161  0  3  164 
submitteda, b  Southwest 53  0  4  57 
West  75  0  0  75 
Number of  Northeast  12  Not applicable  3  15 
Medicare  Southeast 32  Not applicable  8  40 
revocations  Midwest 44  Not applicable  3  47 
recommendeda  Southwest 35  Not applicable  3  38 
West  18  Not applicable  4  22 
Number of  Northeast  0  Not applicable  0  0 
Medicare  Southeast 0  Not applicable  0  0 
exclusions  Midwest 0  Not applicable  0  0 
recommendeda  Southwest 0  Not applicable  0  0 
West  0  Not applicable  0  0 
Number of  Northeast  Not applicable Did not track   Did not track  Did not track  
Medicaid  Southeast  Not applicable  0  0  0 
terminations  Midwest  Not applicable  0  0  0 
recommendeda   Southwest  Not applicable  0  0  0 
West  Not applicable  0  0  0 
Number of civil  Northeast  0  0  0  0 
monetary Southeast  0  0  0  0 
penalties Midwest 0  0  0  0 
recommendeda  Southwest 0  0  0  0 
West  0  0  0  0 
Investigations  Northeast  314  39  42  395 
resulting in Southeast 414  2  95  511 
administrative   Midwest 705  25  79  809 
actions   Southwest  371  40  61  472 
West  360  35  63  458 
Total number of  Northeast  544  Not applicable  Not applicable  544 
Medicare appeals  Southeast  47  Not applicable   Not applicable   47 
handled  Midwest  Unable to determine  Not applicable  Not applicable  Unable to 
  determine  
Southwest 6,529   Not applicable  Not applicable  6,529  
West  3,068   Not applicable  Not applicable  3,068  
Value of  Northeast  $5,532,541   Not applicable  $0  $5,532,541  
Medicare claims  Southeast  $35,379,685   Not applicable  $244,172   $35,623,856  
denied by Midwest $593,981   Not applicable  $0  $593,981  
auto-deny Southwest  $11,109,085   Not applicable  $48,705   $11,157,790  
editsc, d    West  $11,643,680   Not applicable  $0  $11,643,680  
continued on next page  
 
UPICs Hold Promise To Enhance Program Integrity Across Medicare and Medicaid, But Challenges Remain     
OEI-03-20-00330  Appendix A | 29     
Exhibit A-1.  Total program integrity activities conducted by each UPIC across Medicare, 
Medicaid, and Medi-Medi in 2019 (continued) 
    Medicare   Medicaid   Medi-Medi   Total  
Request for  Northeast  448  2  239  689 
information  Southeast  684  0  86  770 
completed  Midwest  848  5  10  863 
  Southwest  484  2  242  728 
West  383  0  0  383 
Request for Northeast  24  3  1  28 
assistance  Southeast 5  0  0  5 
completed  Midwest  23  1  0  24 
Southwest  62  3  3  68 
West  42  3  0  45 
Medical review   Northeast  447  21  83  551 
case requests Southeast  158  14  58  230  
conducted  Midwest 498  57  58  613  
Southwest  272  13  49  334  
West  323  10  44  377  
Compromised  Northeast   2   0   0   2 
beneficiary ID Southeast 38  0  1  39 
numbers  Midwest   Did not track   Did not track   Did not track   Did not track  
identified  Southwest  37  0  0  37 
West  0  0  0  0 
Compromised  Northeast  2  0  0  2 
provider ID Southeast 3  0  0  3 
numbers  Midwest   Did not track   Did not track   Did not track   Did not track  
identified  Southwest  0  0  0  0 
West  0  0  0  0 
Source: OIG analysis of UPICs  responses to OIG request  for  information.  
a Denotes one of the program integrity activities described in the findings of the report.  In the findings, administrative actions recommended  
represents the  sum of the revocations, exclusions, terminations, payment suspensions, and civil monetary penalties recommended  by the 
UPICs.  
b  The UPICs reported  that the Medi-Medi payment suspensions were related to Medicare  providers only.   
c The Medicare, Medicaid, and Medi-Medi amounts may not sum to the total amount because of  rounding.  
d Auto-deny edits prevent payment for services that are billed inappropriately.  
 
 
UPICs Hold Promise To Enhance Program Integrity Across Medicare and Medicaid, But Challenges Remain     
OEI-03-20-00330  Appendix A | 30     
Appendix B: Program Integrity Activities Conducted by UPICs 
for Medicaid Fee-for-Service and Medicaid Managed Care in 
2019 
UPICs reported the number of program integrity activities they conducted in 2019.  If 
a UPIC was unable to provide the data requested, it responded with "Unable to 
determine" or "Did not track. 
Exhibit B-1.  Program integrity activities conducted by each UPIC across Medicaid fee-for-
service (FFS) and Medicaid managed care in 2019 
  Medicaid FFS  Medicaid Managed  Medicaid FFS and  Medicaid 
Care   Medicaid Managed  Total 
Care  
Data analysis  Northeast  Did not track   Did not track   Did not track   22 
projects Southeast   8  0  6  14 
completeda 
Midwest   Did not track   Did not track   Did not track   20 
Southwest   Did not track   Did not track   Did not track   35 
West  9  0  0  9 
Leads screeneda  Northeast  Did not track   Did not track   Did not track   128 
Southeast   21  0  1  22 
Midwest  0  0  167  167 
Southwest   103  5  7  115 
West  142  9  7  158 
Investigations  Northeast  Did not track   Did not track   Did not track   98 
openeda  Southeast 95  125  1  221 
Midwest   Unable to determine  Unable to determine  Unable to determine  120 
Southwest   80  6  9  95 
West  63  0  0  63 
Cases referreda  Northeast  Did not track   Did not track   Did not track   5 
  Southeast   2  0  0  2 
Midwest   Unable to determine   Unable to determine   Unable to determine   8 
Southwest   1  1  0  2 
West  16  0  0  16 
Vulnerabilities   Northeast  Did not track   Did not track   Did not track   0 
identifieda   Southeast   0  0  0  0 
Midwest   0  0  0  0 
Southwest   0  0  0  0 
West  2  0  0  2 
Investigations  Northeast  Did not track   Did not track   Did not track   39 
resulting in Southeast   2  0  0  2 
administrative   Midwest   Unable to determine   Unable to determine   Unable to determine   25 
actions   Southwest   32  2  6  40 
West  35  0  0  35 
continued on next page 
 
UPICs Hold Promise To Enhance Program Integrity Across Medicare and Medicaid, But Challenges Remain   
OEI-03-20-00330  Appendix B | 31     
Exhibit B-1.  Program integrity activities conducted by each UPIC across Medicaid fee-for-
service (FFS) and Medicaid managed care in 2019 (continued)  
    Medicaid FFS  Medicaid Managed  Medicaid FFS and  Medicaid 
Care   Medicaid Managed  Total 
Care  
Request for Northeast  Did not track   Did not track   Did not track   2 
information  Southeast   Did not track   Did not track   Did not track   0 
completed  Midwest   Unable to determine   Unable to determine   Unable to determine   5 
  Southwest   Did not track   Did not track   Did not track   2 
West  0  0  0  0 
Request for Northeast  Did not track   Did not track   Did not track   3 
assistance  Southeast   Did not track   Did not track   Did not track   0 
completed  Midwest   Unable to determine   Unable to determine   Unable to determine   1 
Southwest   Did not track   Did not track   Did not track   3 
West  0  0  3  3 
 Source: OIG  analysis of  UPICs  responses to OIG request  for  information.  
a Denotes one of the program integrity activities described in the findings of the report.   
Note: Upon  reviewing this appendix, CMS noted that UPICs  responses may not align with CMSs requirements and statements on program 
characteristics. 
UPICs Hold Promise To Enhance Program Integrity Across Medicare and Medicaid, But Challenges Remain   
OEI-03-20-00330  Appendix B | 32     
Appendix C: Agency Comments 
Following this page are the official comments from CMS.  
   
UPICs Hold Promise To Enhance Program Integrity Across Medicare and Medicaid, But Challenges Remain   
OEI-03-20-00330  Appendix C | 33    DATE:   September  14,  2022  
TO:   Suzanne Murrin   
Deputy Inspector  General  for  Evaluation  and Inspections  
FROM:   Chiquita Brooks-LaSure  
Administrator  
SUBJECT:   Office  of  Inspector  General  (OIG)  Draft  Report:  UPICs  Hold Promise to 
Strengthen  Program  Integrity in  Medicare and Medicaid,  But  Challenges  Remain  
(OEI-03-20-00330)  
The Centers  for  Medicare &  Medicaid Services  (CMS)  appreciates  the opportunity to review  and 
comment  on  the Office  of  Inspector  Generals  (OIG)  draft  report.  CMS is  committed to program  
integrity efforts  in  Medicare and Medicaid,  including providing effective support  and assistance  
to states  in  their  efforts  to combat  Medicaid provider  fraud and abuse.  
The Medicaid program  is  funded jointly by states  and the federal  government,  and State 
Medicaid Agencies  (SMAs)  administer  the Medicaid program  on  a day-to-day basis  according to 
federal  requirements. SMAs  are responsible for  establishing,  within  broad federal  guidelines,  
various  Medicaid program  requirements,  such  as  who will  be eligible for  benefits,  what  benefits  
will  be covered,  and the service delivery system  to be used to provide Medicaid services,  
typically managed care or  fee-for-service.  This  gives  each  state broad flexibility in  the design  of  
their  respective programs  and thus  results  in  variation  among Medicaid programs.  
One way that  CMS investigates  instances  of  suspected fraud,  waste,  and abuse in  Medicare and 
Medicaid is  through  the activities  of  the Unified Program  Integrity Contractors  (UPICs).  UPICs  
are one piece of  a  complementary network of  efforts  by both  the SMAs  and  federal  government  
to promote Medicaid program  integrity.  States  dedicate resources  to their  Medicaid program  
integrity units  and Medicaid Fraud Control  Units,  while Medicaid managed care plans  have 
Special  Investigative Units  (SIUs),  all  of  which  may investigate potential  fraud,  waste and abuse.  
UPICs  are funded by CMS and operate in  five geographic jurisdictions.  Their  work includes  
Medicare  and Medicaid program  integrity initiatives,  as  well  as  examining data from  both  
Medicare and Medicaid to conduct  analyses  across  programs  (Medi-Medi).  UPICs  work in  close 
collaboration  with  SMAs  to conduct  proactive Medicaid data analysis,  investigations,  and audits  
of  all  types  of  Medicaid providers  including managed care.  The UPICs  also identify 
overpayments  and make fraud referrals  to law  enforcement,  and work closely with  SMAs  to 
ensure their  work aligns  with  state priorities.   
In  addition  to the UPIC  efforts,  CMS  also  promotes  best  practices  and performance  standards  for  
states  to use in  their  fraud prevention  efforts,  conducts  State Program  Integrity Reviews  to assess  
the effectiveness  of  the state's  program  integrity efforts,  and leads  the Medicaid Integrity 
UPICs Hold Promise To Enhance Program Integrity Across Medicare and Medicaid, But Challenges Remmaai n
OEI-03-20-00330  Appendix C | 34   Institute (MII),  which  provides  training tailored to meet  the ongoing needs  of  state Medicaid 
program  integrity employees.   
Since the OIGs  review  period,  CMS has  continued to work to refine and direct  the UPIC  work 
to where it  is  most  effective,  and in  recent  years,  Medicaid managed care work has  risen  to 
represent  about  50 percent  of  the current  Medicaid UPIC  caseload.  Some variation  between  
jurisdictions  and programs  is  expected because the number  of  leads  received,  available budget,  
and type of  investigation  all  affect  workload.  For  example,  Home Health  and Hospice  
investigations  are more complex and consume more resources  than  other  types  of  investigations.  
A  jurisdiction  conducting more Home Health  and Hospice  investigations  may conduct  fewer  
investigations  overall.  In  addition,  the landscape of  fraud varies  throughout  the country.  CMS 
tracks  UPIC  initiatives  and findings  in  detail,  and expects  UPICs  time and  resources  spent  
across  Medicare,  Medicaid,  and Medi-Medi  to generate a positive return  on  investment  with  the 
funding they receive for  each  program.   
CMSs  oversight  includes  tracking workload differences  between  jurisdictions  as  well  as  
working with  UPICs  to explore other  possible reasons  for  these differences.  UPICs  can  access  
the Unified Case Management  (UCM)  system,  which  CMS developed as  a centralized repository 
for  leads  and investigations.  UPICs  create records  in  the UCM  to document  the leads  received,  
results  of  vetting those leads  to determine if  an  investigation  is  warranted,  as  well  as  the 
outcomes  of  those investigations. CMS uses  the UCM  system  to continuously monitor  and 
evaluate UPIC  performance.  CMS is  currently spearheading an  effort  to improve the UCM  
system,  soliciting UPIC  feedback to develop a new  more user-focused system  that  prioritizes  
Human  Centered Design.  
OIGs  recommendations  and CMS'  responses  are below.  
OIG  Recommendation  
CMS should implement  a plan  to increase UPICs  Medicaid program  integrity activities,  
particularly related to managed care.  
CMS Response  
CMS concurs  with  this  recommendation.  CMSs  continuous  improvement  actions  include 
activities  focused on  increasing the UPIC  Medicaid  managed care  program  integrity activities.  
To date,  Medicaid managed care represents  roughly 50 percent  of  the current  Medicaid UPIC  
caseload.  CMS will  continue to ensure the optimal  UPIC  caseload mix for  Medicaid managed 
care.   
OIG  Recommendation  
CMS should make  improvements  to the UCM  system.  
CMS Response  
CMS concurs  with  this  recommendation.  Prior  to this  audit,  CMS had begun  work on  the  
redesign  effort  of  the UCM  in  close collaboration  with  UPICs.  CMS will  continue its  work on  
this  effort  to make  improvements  to the UCM  system.  
UPICs Hold Promise To Enhance Program Integrity Across Medicare and Medicaid, But Challenges Remmaai n
OEI-03-20-00330  Appendix C | 35   OIG  Recommendation  
CMS should implement  a plan  to promote the success  of  the Major  Case Coordination  initiative 
for  Medicaid referrals.  
CMS Response  
CMS concurs  with  this  recommendation.  CMS will  explore ways  to maintain  and enhance  the 
success  of  the Medicaid Major  Case Coordination  initiative and to educate states  on  how  this  
collaboration  can  help them  fight  fraud.   
OIG  Recommendation  
CMS should identify the reasons  for  the unexplained variation  in  program  integrity activities  across  
UPICs.  
CMS Response  
CMS concurs  with  this  recommendation.  CMS continuously monitors  the program  integrity 
activities  performed across  UPICs  to ensure the optimal  use of  program  integrity resources.  As  
part  of  this  monitoring,  we expect  variations  between  jurisdictions  and programs  due to a number  
of  factors,  including the number  of  fraud leads  received,  available budget,  and type of  
investigations.  For  example,  Home Health  and Hospice  investigations  are more complex and 
consume more resources  than  other  types  of  investigation.  
CMS thanks  OIG  for  their  efforts  on  this  issue and looks  forward to working with  OIG  on  this  and 
other  issues  in  the future.  
UPICs Hold Promise To Enhance Program Integrity Across Medicare and Medicaid, But Challenges Remmaai n
OEI-03-20-00330  Appendix C | 36    
ACKNOWLEDGMENTS AND CONTACT 
Acknowledgments 
Tanaz Dutia served as the team leader for this study.  Others in the Office of 
Evaluation and Inspections who conducted the study include Nancy J. Molyneaux, 
Matthew Katz, and Emily A. Dieckman.  Office of Evaluation and Inspections staff who 
provided support include Robert Gibbons, Kevin Manley, and Christine Moritz.  
This report was prepared under the direction of Linda Ragone, Regional Inspector 
General for Evaluation and Inspections in the Philadelphia regional office, and Edward 
K. Burley, Deputy Regional Inspector General.  
Contact 
To obtain additional information concerning this report, contact the Office of Public 
Affairs at Public.Affairs@oig.hhs.gov. OIG reports and other information can be found 
on the OIG website at oig.hhs.gov.  
Office of Inspector General 
U.S. Department of Health and Human Services
330 Independence Avenue, SW 
Washington, DC 20201  
 
UPICs Hold Promise To Enhance Program Integrity Across Medicare and Medicaid, But Challenges Remain     
OEI-03-20-00330  Acknowledgments and Contact | 37    
ABOUT THE OFFICE OF INSPECTOR GENERAL 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 
95-452, as amended, is to protect the integrity of the Department of Health and 
Human Services (HHS) programs, as well as the health and welfare of beneficiaries 
served by those programs.  This statutory mission is carried out through a nationwide 
network of audits, investigations, and  inspections conducted by the following 
operating components: 
The Office of Audit Services (OAS)  provides auditing services for HHS, 
either by conducting audits with its own audit resources or by overseeing audit work 
done by others. Audits examine the performance of HHS programs and/or its 
grantees and contractors in carrying out their respective responsibilities and are 
intended to provide independent assessments of HHS programs and operations.  
These audits help reduce waste, abuse, and mismanagement and promote economy 
and efficiency throughout HHS. 
The Office of Evaluation and Inspections (OEI)  conducts national 
evaluations to provide HHS, Congress, and the public with timely, useful, and reliable 
information on significant issues.  These evaluations focus on preventing fraud, waste, 
or abuse and promoting economy, efficiency, and effectiveness of departmental 
programs. To promote impact, OEI reports also present practical recommendations 
for improving program operations. 
The Office of Investigations (OI)  conducts criminal, civil, and administrative 
investigations of fraud and misconduct related to HHS programs, operations, and 
beneficiaries. With investigators working in all 50 States and the District of Columbia, 
OI utilizes its resources by actively coordinating with the Department of Justice and 
other Federal, State, and local law enforcement authorities.  The investigative efforts 
of OI often lead to criminal convictions, administrative sanctions, and/or civil 
monetary penalties. 
The Office of Counsel to the Inspector General (OCIG) provides 
general legal services to OIG, rendering advice and opinions on HHS programs and 
operations and providing all legal support for OIGs internal operations.  OCIG 
represents OIG in all civil and administrative fraud and abuse cases involving HHS 
programs, including False Claims Act, program exclusion, and civil monetary penalty 
cases. In connection with these cases, OCIG also negotiates and monitors corporate 
integrity agreements. OCIG renders advisory opinions, issues compliance program 
guidance, publishes fraud alerts, and provides other guidance to the health care 
industry concerning the anti-kickback statute and other OIG enforcement authorities.  
UPICs Hold Promise To Enhance Program Integrity Across Medicare and Medicaid, But Challenges Remain     
OEI-03-20-00330  About the Office of Inspector General | 38