Audit Defense: What Health Care Providers and Attorneys Need to Know
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This episode of AHLA Speaking of Health Law is sponsored by LW Consulting. For more information, visit lw-consult.com.
Hello, everyone. My name's Harriet Wall. I'm the president and CEO of LW Consulting. And I am here with my colleague, Rachel Holdweiss. And we are going to talk about audit defense. Just a little bit about LW. We are a woman-owned business based in Harrisburg, Pennsylvania, and we serve acute and post-acute care sectors of the industry. More than 50% of our work is done under attorney-client privilege, so we're very well-versed in working with attorneys. And we also serve as an independent review organization for providers with reporting issues. responsibilities under a corporate integrity agreement and help with compliance program readiness and cost reports and other audit, and documentation-related services.
Rachel, thank you for joining me on the podcast today and taking time to share your expertise. Would you please introduce yourself to the listeners?
Yeah, thank you so much, Harriet. My name is Rachel Holdweiss. I'm a partner at the Law Firm of Vanish, Friedlander, Copeland, and Aronoff. I'm in their health group in New York. I represent providers across the spectrum in regulatory, compliance, auditing, and appeals work, which is where Harriet and I do a lot of work together. I'm also a physician assistant and I can't believe I'm saying it's now 30 years, but I'm licensed to practice and I did practice as a PA So from the clinical side, I have a bit of a different perspective. And from the legal side, we work together with LW for many of our clients to work on the appeals that so many of our clients are going through now.
Well, thank you, Rachel. You know, there are a lot of different types of government contractor auditors and commercial payer audits available. And while the audit defense strategies may vary by audit types, there are similar elements as well. However, the unified program integrity contractor, or better known as UPIC audits, they really seem to stand out as a type that evokes a higher level of concern than the others. I know you're deeply entrenched in helping providers defend against UPIC audits and investigations, and we've done a lot of that work together as well. Rachel, how serious is a UPIC audit?
Well, I would say a YouPick audit is pretty serious because as the name implies, it's an integrity contractor. So as you mentioned, there are a lot of contractors that are looking at providers across the board. But once you have integrity in the contractor's name or integrity as part of what they're looking for, they're automatically looking for fraud. Now, that doesn't mean just because you have an audit, you've committed fraud or they suspect you are committing fraud. but there's something aberrant. And so the UPIC auditor will be looking at your claims, prepay or postpay, um, to see if there actually is some fraudulent activities. And there are three UPIC auditors. So not too many. It's not like the max that they're all across the board.
They're divided, um, jurisdictionally by the country. So the names of just our SGS, North and South, and then you've got Covent Bridge and you've got Clarence. So if you get a letter from any of those, that's automatically a UPIC. They don't do anything else but that.
And how do the UPICs decide who to audit?
So there are a bunch of different factors. UPICs can get referrals from other auditors, the alphabet soup that we haven't talked about. That's a whole session in and of itself. So they can get referrals because somebody, some other auditor didn't audit and found something that they think the UPICs should look into. Many of the UPIC audits are targeted by industry. For example, any of the hospice providers, particularly in what we call the hot states, you know, the six states that were under additional scrutiny. The UPIC auditors were very, very active. California is obviously the most active. There are certain other types of products, like we do a lot of wound care work for wound care providers who use skin substitutes.
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Chapters
4 chapters
1
What is the main topic discussed in this episode?
0:04–14:52
2
What is a UPIC audit and why is it considered serious for providers?
14:52–19:37
3
How do Unified Program Integrity Contractors decide which providers to audit?
19:37–27:22
4
What are the five levels of the UPIC audit appeal process?
27:22–31:05
Speakers
2 identifiedMore from AHLA's Speaking of Health Law
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