Qlarant Audits

If you have received notice that Qlarant Integrity Solutions is auditing your Medicare or Medicaid billing, you should understand what they are, what authority they have, and what is at stake — before you respond.

What Is Qlarant Integrity Solutions?

Qlarant Integrity Solutions is a private contractor retained by the Centers for Medicare & Medicaid Services (CMS) to identify and investigate fraud, waste, and abuse in federal health care programs. Qlarant operates in two primary roles — as a Unified Program Integrity Contractor (UPIC) and as the Investigations Medicare Drug Integrity Contractor (I-MEDIC) — giving it broad authority to audit providers across a wide range of Medicare and Medicaid programs.

Unlike routine Medicare Administrative Contractor (MAC) audits focused on billing compliance, Qlarant’s mandate is specifically investigative. Its findings can lead to payment suspensions, recoupments, exclusions from federal programs, and — critically — referrals to the Department of Justice (DOJ) for criminal prosecution or civil False Claims Act enforcement.

Qlarant as a UPIC: West and Southwest Region

As a Unified Program Integrity Contractor, Qlarant is responsible for the West and Southwest jurisdictions, covering states including Texas, California, Nevada, Arizona, and others. In this role, Qlarant investigates Medicare Parts A, B, C, and D billing as well as Medicaid claims, with authority to coordinate directly with law enforcement and CMS.

The UPIC program replaced the former Zone Program Integrity Contractors (ZPICs) and Medicaid Integrity Contractors (MICs), consolidating their authority under a single contractor. This consolidation means Qlarant has a broader and more unified investigative reach than its predecessors.

Qlarant as I-MEDIC: Medicare Parts C & D

As the I-MEDIC contractor, Qlarant investigates fraud, waste, and abuse specifically in Medicare Advantage (Part C) and Medicare Prescription Drug (Part D) plans. This includes auditing plan sponsors, pharmacy benefit managers (PBMs), pharmacies, and prescribers for potential fraud involving prescription drug billing and plan overpayments.

The I-MEDIC role gives Qlarant national reach for Part C and D investigations, meaning providers and plan sponsors anywhere in the country may find themselves under scrutiny regardless of geographic location.

RIViR: Data Analytics as an Investigative Weapon

Qlarant employs a proprietary data analytics platform called RIViR (Risk, Identification, Visualization, and Reporting) to detect billing anomalies across enormous volumes of claims data. RIViR identifies statistical outliers — providers whose billing patterns deviate significantly from peers in the same specialty, region, or practice setting.

What this means in practice is that a provider may be flagged not because any individual claim was necessarily improper, but because their aggregate billing profile is statistically unusual. High volumes of a particular procedure code, unusual patterns in diagnosis coding, or elevated reimbursements relative to peers can all trigger a Qlarant investigation — even in the absence of a complaint or tip.

Once flagged by RIViR, Qlarant may request records, conduct site visits, interview employees, or deploy what are known as “jump teams.”

Jump Teams: Rapid On-Site Investigations

Qlarant’s “jump teams” are rapid-response investigative units that can be deployed quickly to conduct unannounced or short-notice on-site investigations at a provider’s office, clinic, or facility. These teams may arrive alongside or in coordination with federal agents from the HHS Office of Inspector General (OIG), the FBI, or other law enforcement agencies.

A jump team visit is a serious escalation. It typically indicates that Qlarant has already identified specific concerns about your billing practices and is gathering evidence for potential referral or administrative action. Providers who encounter a jump team should immediately contact legal counsel before providing any statements, documents, or access beyond what is legally required.

Recoupments, Payment Suspensions, and DOJ Referrals

A Qlarant audit can result in several significant actions against a provider or organization:

What to Do If You Receive a Qlarant Audit Notice

Time is critical. How you respond to a Qlarant audit — especially in the early stages — can significantly affect the outcome. Providers who respond without experienced legal counsel often make mistakes that complicate their defense or provide investigators with additional grounds for referral.

You should retain federal defense counsel immediately upon receiving any communication from Qlarant, including record requests, site visit notices, or payment suspension letters. An attorney experienced in federal health care fraud defense can help you evaluate your exposure, respond appropriately to document requests, protect your rights during any on-site investigation, and engage strategically with CMS and the DOJ if a referral occurs.