UPIC Audit Attorney

UPIC regulatory expertise

Legal Defense for UPIC Audits & Appeals

Anthony Mahajan & Alison Goldman

Your UPIC Audit Defense Team · Health Law Alliance

At Health Law Alliance, our healthcare defense attorneys aggressively challenge improper UPIC audit tactics, unsupported extrapolations, and abusive recoupment actions. Backed by decades of healthcare regulatory and enforcement experience, our team develops strategic, results-driven defenses, helping you navigate UPIC investigations with confidence.

CMS and its UPICs are taking an increasingly aggressive approach to intimidate healthcare providers with overpayment demands and Medicare fraud allegations. We bring the firepower to these fights – so UPICs cannot pad their profits with audit recoupments from you.

The federal government and CMS have incentivized UPICs, including SafeGuard, CoventBridge, and Qlarant, to become more active in controlling Medicare spend. As a result, specialized task forces are accusing providers of “credible allegations of fraud” based solely on data, not good faith audits or investigations.

‍Call the Nation’s Leading Healthcare Audit Defense Firm
UPIC audits can begin with seemingly routine requests for records but quickly escalate into huge overpayment notices and recoupment demands. Our UPIC audit attorneys stop aggressive audit overreach at each step in the process:

—

RAC or UPIC Records Request Response

—

UPIC Payment Suspension Rebuttal

—

UPIC Enrollment Revocation/Preclusion

—

Request for Redetermination of CMS’s Overpayment Demand

—

Request for Reconsideration by a Qualified Independent Contractor (QIC)

—

Appeal to an Administrative Law Judge (ALJ)

—

Review by the Medicare Appeals Council

How We Help

Full Service UPIC Audit Defense

⚖️

CMS & UPIC Audits

Recovery Audit Contractors (RACs) including Performant, Cotiviti, Health Management Systems or HMS, and other Medicare audit contractors

Unified Program Integrity Contractors (UPICs) including CoventBridge Group, SafeGuard Services (SGS), Qlarant, Health Integrity, and other CMS program integrity contractors

Medicare Administrative Contractors (MACs) including Palmetto GBA, Novitas, NGS, WPS, CGS, First Coast, Noridian, and related Medicare contractors

🛡️

Regulatory & Enforcement Defense

HHS-OIG Subpoenas & Civil Investigative Demands (CIDs)

Fraud, Waste & Abuse (FWA) Investigations

False Claims Act Defense

Grand Jury Subpoenas, Criminal Investigations & Prosecutions

🧪

Common Issues Identified During UPIC Audits

Medical necessity allegations

Insufficient documentation

Modifier usage issues

Signature and authentication deficiencies

Billing for services allegedly not rendered

Telemedicine compliance concerns

Duplicate billing allegations

Incident-to billing issues

Conflicting documentation

Formulaic/unoriginal documentation

Evaluation & Management coding issues

Laboratory testing utilization

DME documentation deficiencies

Prescription validation issues

Inventory reconciliation issues

Prior authorization discrepancies

Statistical billing outliers

Failure to maintain supporting documentation

Improper site of service

📋

Potential Consequences of a UPIC Audit

A UPIC audit can quickly escalate far beyond a routine records request, including

Medicare payment suspensions

Extrapolated overpayment demands

Revocation of billing privileges

Prepayment review

OIG investigations

False Claims Act lawsuits

Criminal healthcare fraud investigations

DEA investigations

Medicaid exclusion

Licensure actions

GLP-1 Compliance Consulting

· Structuring compliant GLP-1 telehealth programs

· Advertising & marketing claims review

· Off-label compounding & patient consent

· Labeling risk mitigation

Regulatory Defense

· FDA inspections & Warning Letters

· DOJ and HHS-OIG investigations

· DEA controlled substance compliance

· State pharmacy & medical board actions

· False Claims Act defense

Compounding Pharmacy Guidance

· 503A and 503B compliance

· Evaluating compounding pharmacy relationships

· Drug shortage documentation

· API sourcing compliance

· Responding to “essentially copies” allegations

Investigations & Litigation

· Pharmaceutical manufacturer lawsuits

· FDA and DEA enforcement actions

· Reimbursement disputes with PBMs

· Telehealth prescribing investigations

· Patent dispute defense

GLP-1 Compliance Consulting

Structuring compliant telehealth programs · Advertising & marketing claims review · Off-label compounding, patient consent & labeling risk mitigation

Regulatory Defense

FDA inspections & Warning Letters · DOJ and HHS-OIG investigations · DEA controlled substance compliance · State pharmacy & medical board actions · False Claims Act defense

Compounding Pharmacy Guidance

503A and 503B compliance · Drug shortage documentation & API sourcing · Responding to “essentially copies” allegations · Evaluating compounding pharmacy relationships

Investigations & Litigation

Pharmaceutical manufacturer lawsuits & patent defense · FDA and DEA enforcement actions · Reimbursement disputes with PBMs · Telehealth prescribing investigations

Every hour matters in a UPIC audit.

Free Consultation

Facing a UPIC Audit?

✓

Recent Outcome

FDA warning letter resolved for compounding clinic — no further enforcement action.

✓

Recent Outcome

UPIC overpayment demand successfully challenged - no further recoupment.

We defend pharmacies, physicians, labs, DMEPOS suppliers, telemedicine companies, behavioral health practices, home health agencies, hospices, clinics, substance abuse centers, and certified wound care providers against UPIC audits, Medicare recoupments, suspensions, enrollment revocations, False Claims Act allegations, and healthcare fraud investigations. Our UPIC audit attorneys represent providers at every stage of the UPIC audit and appeals process, helping protect licenses and livelihoods nationwide.

Thank you! Your submission has been received!

Oops! Something went wrong while submitting the form.

100% Confidential & Secure

“I personally review every UPIC audit matter within 24 hours.” — Anthony Mahajan

★★★★★

★

5.0 · 47 reviews

Confidential

No Obligation

24hr Response

Why Health Law Alliance

This is some text inside of a div block.

Former Regulators. Now Fighting for You.

"We Used to Work for Them. Now We Fight for You."

Former Government Regulators on Your Side

Our team is led by former federal and state prosecutors who understand exactly how the government builds cases against healthcare providers. We use their own playbook to beat them.

Healthcare Specialty Attorneys & Consultants

Our founding partner served as a top executive for McKesson, Relay Health, CoverMyMeds, United Health Group, Optum, and United Healthcare. We know how the system works from the inside.

Proven Track Record

From UPIC audits, Medicare overpayment appeals, and payment suspension actions to DEA investigations, False Claims Act litigation, healthcare fraud investigations, and complex criminal prosecutions, our healthcare defense attorneys have successfully represented providers across the full spectrum of regulatory and enforcement matters. We fight aggressively at every stage of the process, protecting healthcare providers from the initial UPIC audit through appeals, investigations, litigation, settlement negotiations, and trial when necessary.

Call Now — (800) 345-4125

Call Now — (888) 858-6446

1,250+

Satisfied Clients

"Trustworthy & Experienced — they knew exactly what CMS was going to do next."

— Ali M., Provider

— Ali M., Compounding Pharmacy

"You will want them in your corner. Resolved our warning letter in under 30 days."

— Seth M., Clinic

— Seth M., GLP-1 Clinic

"Subject matter experts who understand both the clinical and legal side."

— Ahmed B., Telehealth Provider

"Trustworthy & Experienced — they knew exactly what the FDA was going to do next."

— Ali M., Compounding Pharmacy

"You will want them in your corner. Resolved our warning letter in under 30 days."

— Seth M., GLP-1 Clinic

"Subject matter experts who understand both the clinical and legal side."

— Ahmed B., Telehealth Provider

Frequently Asked

Questions About UPIC Audits

What is an UPIC audit?+

A UPIC audit is a Medicare or Medicaid investigation conducted by a Unified Program Integrity Contractor (“UPIC”) to identify suspected fraud, waste, abuse, billing irregularities, or documentation deficiencies involving healthcare providers, pharmacies, and suppliers.

What triggers an UPIC audit?+

UPIC audits may be triggered by billing patterns, data analytics, whistleblower complaints, high utilization rates, patient complaints, unusual prescribing trends, prior audits, or referrals from CMS, Medicaid agencies, PBMs, or other government entities. UPICs are increasingly utilizing AI to conduct data mining, analyze audit documentation, and identify targets.

Can a UPIC audit lead to criminal charges?+

Yes. UPIC audits can result in referrals to the DOJ, OIG, DEA, state Medicaid Fraud Control Units, or federal prosecutors for potential civil or criminal healthcare fraud investigations.

Can Medicare or Medicaid payments be suspended during a UPIC audit?+

Yes. CMS or Medicaid agencies may suspend payments during a UPIC investigation if there is an alleged “credible allegation of fraud,” even before liability is formally established. These suspensions can last up to 180 days, and can be extended as the investigation continues.

What happens after a UPIC audit?+

After a UPIC audit, providers may face overpayment demands, extrapolated recoupments, payment suspensions, Medicare revocation and preclusion, Medicaid termination, payor actions, or referrals to other investigative agencies.

What is an extrapolated overpayment?+

An extrapolated overpayment occurs when auditors review a limited sample of claims and then project alleged errors across a much larger universe of claims, often resulting in massive repayment demands.

Should I respond to a UPIC audit without an attorney?+

Healthcare providers should strongly consider retaining experienced healthcare defense counsel before responding to a UPIC audit. Statements, records production, and audit responses can significantly impact future civil, administrative, or criminal proceedings.

Can a UPIC audit affect my medical license or DEA registration?+

Yes. Findings from a UPIC audit may be referred to licensing boards, the DEA, or other regulatory agencies, potentially impacting a provider’s license, prescribing authority, or enrollment status.

How long does a UPIC audit last?+

UPIC audits can last months or even years, depending on the scope of the investigation, the volume of records requested, and whether the matter escalates into additional enforcement proceedings.

Can a provider appeal a UPIC overpayment determination?+

Yes. Healthcare providers generally have multiple levels of appeal available, including redeterminations, reconsiderations, and Administrative Law Judge hearings. Appealing quickly can stop the recoupment throughout the duration of the appeals process.

What types of providers are targeted in UPIC audits?+

UPIC audits can target physicians, pharmacies, telemedicine companies, DME suppliers, wound care providers, laboratories, behavioral health providers, home health agencies, pain management clinics, and virtually any healthcare provider billing Medicare or Medicaid.

What should I do if I receive a UPIC records request?+

Providers should immediately preserve records, identify all deadlines, avoid making informal statements to auditors, and consult experienced healthcare defense counsel before producing documentation or responding to the investigation.

Can a UPIC audit trigger a False Claims Act investigation?+

Yes. UPIC audits frequently lead to civil False Claims Act investigations involving allegations of improper billing, lack of medical necessity, kickbacks, or fraudulent claims submissions.

Why hire a healthcare defense attorney for a UPIC audit?+

An experienced healthcare defense attorney can help protect provider enrollment, challenge overpayment demands, defend against payment suspensions, minimize regulatory exposure, and prevent escalation into civil or criminal investigations.

Free Consultation

UPIC Audit Attorneys

Legal Defense for UPIC Audits & Appeals

Full Service UPIC Audit Defense

Former Regulators. Now Fighting for You.

UPIC Audits Move Fast. So Do We.

Questions About UPIC Audits

Book a Free Consultation