Strategic Legal Representation for UPIC Audits
UPIC audits are becoming increasingly common and aggressive, particularly for small to mid-sized healthcare providers. While these audits can disrupt operations and threaten revenue, they don’t have to shut your practice down. At JurisHealth, our staff aids healthcare providers to navigate UPIC audits and Medicare appeals with experienced legal guidance, providing clarity and support at every stage of the process.
Our Approach to UPIC & Medicare Appeals
Our approach to UPIC audits and Medicare appeals is methodical, defense-driven, and focused on protecting healthcare providers through:
Regulatory Expertise & Compliance Guidance
Documentation &
Claims Review
Overpayment & Recoupment Defense
Strategic UPIC
Audit Navigation
UPICs & Medicare Appeals
Unified Program Integrity Contractors (UPICs) are government contractors tasked with detecting potential fraud, waste, and abuse in Medicare and Medicaid. UPICs audit healthcare providers by examining medical records, billing practices, and claims data for compliance and medical necessity.
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​Were a UPIC audit result in alleged overpayments or adverse findings, those determinations often lead to claim denials, payment suspensions, or repayment demands that must be challenged through the Medicare appeals process. Early audit responses frequently shape the scope, strategy, and outcome of subsequent appeals.
UPIC audits are not routine reviews - they are enforcement-driven investigations.
For healthcare providers, a UPIC audit can quickly escalate from a documentation request into overpayment findings or even enforcement referrals. Understanding UPICs is essential to protecting your practice.​
The Critical Pre-Appeals Stage
The pre-appeals stage is the most critical stage of the medicare appeal lifecycle. The pre-appeals stage is where the outcome of a UPIC audit is often determined, the decisions made here set the course for the entire case.
Strict Deadlines Enforced
Dictates Case Arguments
UPIC Request for Records
Document Request Issued
Reviewed for Compliance
Reviewed for Necessity
Medical Records Submission
Organized Applicable Records
Possible Case Advances
No Chances to Fix Past Errors
Medical Records Submission
Overpayment or Extrapolation
Levels of Appeal in UPIC Cases
If a UPIC decision is unfavorable, providers can pursue appeals through multiple levels.
Level 1: Redetermination (MAC)
First Level of Medicare Appeal
Redetermination is the first step in challenging a UPIC overpayment determination. The Medicare Administrative Contractor (MAC) that processed the original claims reviews the appeal to determine whether the services were reasonable, necessary, and compliant with Medicare rules.
Reviewer: Medicare Administrative Contractor (MAC)
Purpose: Reverse overpayment determination
Evidence Allowed: Medical records and coverage guidance
File Deadline: 120 days from demand letter
Common risk: Incomplete documentation
Each level of appeal is governed by strict deadlines and precise procedural requirements.
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Contact Us
24W500 Maple Avenue Suite 219
Naperville, Illinois 60540​-6057​​
​(630) 995-9220​​
​(630) 383-7056 ~ Facsimile​