UPIC & ZPIC Audits
If you have received a records request, site visit notice, or payment suspension tied to a UPIC or ZPIC investigation, you are facing one of the most serious forms of Medicare fraud scrutiny available to CMS. These are not routine billing audits — they are fraud investigations with direct lines to the Department of Justice.
What Is a UPIC?
A Unified Program Integrity Contractor (UPIC) is a CMS-contracted investigative entity responsible for detecting and combating fraud, waste, and abuse across Medicare Parts A, B, C, and D, as well as Medicaid. UPICs replaced the previous Zone Program Integrity Contractors (ZPICs) and Medicaid Integrity Contractors (MICs), consolidating their authority into a single, more powerful investigative framework.
There are five UPIC jurisdictions covering the entire United States. Qlarant Integrity Solutions serves the West and Southwest regions. Other UPICs cover the Midwest, Southeast, Northeast, and South. Each UPIC has authority to investigate any provider billing Medicare or Medicaid in its jurisdiction.
What Is a ZPIC?
Zone Program Integrity Contractors were the predecessors to UPICs, operating from roughly 2010 to 2018. Though ZPICs no longer exist as a formal program, their legacy investigations continue in some cases, and many providers who were investigated under ZPIC authority later faced UPIC follow-up or DOJ referral. Providers who received ZPIC correspondence or are dealing with matters that originated during that era should still seek legal counsel experienced with program integrity investigations.
How UPIC Investigations Begin
UPIC investigations are typically initiated through one of three pathways: data analysis (flagging providers whose billing patterns deviate significantly from peers), complaints or tips from beneficiaries, employees, or competitors, and referrals from other agencies such as Medicare Administrative Contractors (MACs), the OIG, or law enforcement.
Once a provider is flagged, the UPIC may conduct a passive review of claims data, issue a request for medical records, schedule or conduct an unannounced site visit, interview employees or beneficiaries, or recommend a payment suspension to CMS — all before the provider is formally notified of an investigation.
UPIC Authority: What They Can Do
Request Medical Records
UPICs can demand medical records for any claims submitted to Medicare or Medicaid. Failure to respond within the required timeframe can result in automatic denial of claims and be used as evidence of non-cooperation.
Conduct Site Visits
UPICs may conduct announced or unannounced visits to a provider’s practice location. These visits can include observation of operations, interviews with staff, and review of physical records. Providers should have legal counsel before participating in any interview.
Recommend Payment Suspension
When a UPIC has “reliable information” of fraud, it can recommend that CMS immediately suspend all Medicare payments to a provider. This can halt a practice’s revenue entirely while the investigation proceeds.
Refer to DOJ or OIG
UPICs have a direct referral relationship with the Department of Justice and the HHS Office of Inspector General. A UPIC referral can initiate a criminal investigation, a False Claims Act civil action, or an exclusion proceeding.
How to Respond to a UPIC Investigation
The single most important step is to retain experienced federal defense counsel before making any substantive response to a UPIC inquiry. Statements made to UPIC investigators, records voluntarily provided beyond what is legally required, and uncoordinated responses to site visits can all significantly harm your legal position.
An attorney can help you understand exactly what the UPIC is authorized to request, what you are legally required to provide, how to respond in a way that protects — rather than waives — your rights, and how to engage proactively with CMS if a payment suspension is threatened or issued.
Under UPIC or ZPIC Investigation?
Justo Mendez, J.D., M.H.A., LL.M. represents healthcare providers in UPIC investigations, payment suspensions, and DOJ referrals across the country.
With a background in both law and health administration, he understands the clinical, regulatory, and legal dimensions of program integrity investigations.