Fraud & Abuse
Medicare fraud can cost the United States government hundreds of millions of dollars each year and the dollars lost increase the strain on the Medicare Trust Fund. CMS works with other government contractors and law enforcement agencies to protect the Medicare Program from fraud and abuse. The following information provides you with important information about fraud and abuse as well as the government contractors and agencies responsible for protecting the Medicare Trust Fund.
Unified Program Integrity Contractor (UPIC)
The primary goal of UPIC is to detect, prevent and proactively deter fraud, waste and abuse in the Medicare and Medicaid Programs. Functions of the UPIC include:
- Identifying program vulnerabilities by performing data analysis
- Investigating allegations of fraud, waste or abuse from providers, beneficiaries, National Government Services the OIG or CMS.
- Initiating the appropriate administrative actions to support evidence of fraudulent activity including prepayment or post payment medical review, payment suspension activations, and/or revocation actions.
- Refering any identified improper payments for recoupments to NGS for processing and collection
NGS refers suspected fraudulent activity to the UPIC for additional investigation. This may include results found from:
- Provider medical review results
- Beneficiary complaints, or
- Data analysis
The UPIC contracts operate in five separate geographical jurisdictions in the United States and combine and integrate functions previously performed by the ZPIC, PSC and MIC contracts. The following table lists the current UPIC by jurisdiction and includes the states with each jurisdiction:
| UPIC Name | Region | States in Region |
|---|---|---|
| Qlarant Integrity Solutions, LLC | Western | Alaska, Arizona, American Samoa, Guam, Hawaii, Idaho, Montana, Nevada, North Dakota, Northern Mariana Islands, Oregon, South Dakota, Utah, Washington, Wyoming |
| CoventBridge Group | Midwestern | Illinois, Indiana, Iowa, Kansas, Kentucky, Michigan, Minnesota, Missouri, Nebraska, Ohio, Wisconsin |
| Qlarant Integrity Solutions, LLC | Southwestern | Arkansas, Colorado, Louisiana, Mississippi, New Mexico, Oklahoma, Texas |
| Safeguard Services, LLC (SGS) | Northeastern | Pennsylvania, New York, Delaware, Maryland, D.C., New Jersey, Massachusetts, New Hampshire, Vermont, Maine, Rhode Island, Connecticut |
| Safeguard Services, LLC (SGS) | Southeastern | Alabama, Florida, Georgia, North Carolina, Puerto Rico, South Carolina, Tennessee, Virgin Islands, Virginia, West Virginia |
All fraud cases developed by the UPICs are referred to the OIG for consideration and initiation of criminal or civil prosecution, civil monetary penalty, or administrative sanction actions. If the UPICs determines a situation is not fraud, they refer the case back to NGS for additional provider education, medical review, and/or other appropriate actions
Revised 12/20/2024