Hospice UPIC Prepayment Review: Which Records They Request and How to Build Your Response

When a Unified Program Integrity Contractor (UPIC) places a hospice on prepayment review, Medicare stops paying the hospice's claims until the UPIC reviews the medical records for each selected claim. Cash flow can slow sharply or stop. The response deadline is short, and the review is conducted by a contractor whose job is to identify fraud, waste, and abuse.

Hospice UPIC activity has increased sharply in 2026. In California, the Western Jurisdiction UPIC issued payment suspension notices to hundreds of hospices in April. In Texas, CMS leaders publicly announced increased hospice scrutiny after state testimony that the number of licensed hospices had nearly doubled since 2020. CMS imposed a nationwide moratorium on new hospice enrollment in May and maintains heightened oversight of newly enrolled hospices in Arizona, California, Georgia, Nevada, Ohio, and Texas.

A strong prepayment review response can make the difference between paid claims and a growing pile of denials that may lead to further action. This article explains what UPIC prepayment review is, why hospices are selected, which records UPICs typically request, how to build a complete response, appeal rights, and when to involve counsel. It is educational and does not replace legal advice.

What a UPIC Is

UPICs are CMS contractors that perform program integrity activities for Medicare and Medicaid, including data analysis, medical review, investigations, and referrals to law enforcement. CMS's Medicare Program Integrity Manual, Chapter 4, describes their program integrity role. UPICs are organized by geographic jurisdiction. Qlarant Integrity Solutions serves as the UPIC for the Western and Southwestern jurisdictions, which include California and Texas.

UPIC review differs from Medicare Administrative Contractor (MAC) review:

• UPICs focus on potential fraud, waste, and abuse.

• UPICs can refer matters to the HHS Office of Inspector General and the Department of Justice.

• UPICs can recommend payment suspensions and revocations.

• UPICs can use statistical sampling and extrapolation in postpayment reviews.

What Prepayment Review Means

Under 42 CFR 405.903, a contractor may select claims for prepayment review and request additional documentation before making a payment decision. When a hospice is on UPIC prepayment review:

• Selected claims are held until the UPIC reviews documentation.

• The hospice receives an Additional Documentation Request (ADR) for each selected claim.

• CMS guidance generally gives providers 30 days to respond to UPIC ADRs.

• If the hospice does not respond on time, the claim may be denied under 42 CFR 405.930.

• The UPIC reviews the records and makes a payment decision, which is an initial determination with appeal rights.

Prepayment review may apply to some or all of a hospice's claims and may continue until the UPIC is satisfied that the hospice's billing is accurate, or until the UPIC takes other action.

Why Hospices Are Selected

UPICs use data analysis and other information to identify hospices for review. Indicators that may lead to selection include:

• High live discharge rates, especially combined with long lengths of stay.

• A high share of patients with stays over 180 days.

• Live discharges followed by readmission within a short time.

• High non-hospice Medicare spending during hospice elections.

• Unusual levels of care, such as frequent general inpatient or continuous home care, or none at all.

• Few skilled visits in the last days of life.

• Rapid growth in census or billing.

• New enrollment or recent changes in ownership.

• Shared addresses, owners, or managing employees with other suspect providers.

• Unusual referral patterns or certifying physicians.

• Complaints, hotline tips, or law enforcement information.

CMS's Service and Spending Variation Index, finalized in the FY 2027 hospice final rule, includes several of these measures.

Records UPICs Typically Request

The ADR will list what the UPIC wants. Hospices should read each ADR carefully, because requests vary. Common requests for hospice claims include:

Election and Admission

• The hospice election statement, with all required elements.

• The election statement addendum, for elections on or after October 1, 2026, or when requested before that date.

• Documentation of any change in attending physician.

• Representative authority documentation, when a representative signed.

• Referral information and admission assessment.

• Records from the referring physician, hospital, or facility.

Certifications

• The initial certification of terminal illness, signed by the hospice physician and the attending physician, if any.

• All recertifications for the benefit periods under review.

• Physician narratives and attestations.

• Face-to-face encounter documentation and attestations for third and later periods.

• Documentation of oral certifications, when applicable.

Clinical Records

• The comprehensive assessment and updates.

• The interdisciplinary group plan of care and updates.

• Interdisciplinary group meeting notes.

• Physician and nurse practitioner notes.

• Nursing visit notes.

• Hospice aide, social work, chaplain, and therapy notes.

• Medication profiles and medication administration records.

• Physician orders, including verbal orders.

Level of Care

• For general inpatient care, documentation supporting each day, facility records, and the facility agreement.

• For continuous home care, time records and documentation for each day.

• For respite, documentation of dates and setting.

Discharge and Revocation

• Revocation statements.

• Discharge orders, summaries, and notices.

Signatures and Staff

• Signature logs or attestations for illegible signatures.

• Staff licenses or credentials, when requested.

Other Items

UPICs may also request information about the hospice's operations, such as policies, staff lists, contracts with facilities, or information about relationships with physicians and referral sources. Requests that go beyond medical records may signal an investigation, and counsel should be involved.

Building the Response Packet

Step 1: Log and Calendar Every ADR

• Record the date received, claim, beneficiary, dates of service, and due date.

• Assign an owner for each ADR.

• Track status daily.

Step 2: Assemble the Complete Record

• Gather every document requested and any other documentation that supports the claim.

• Include records from contracted facilities and outside providers that the hospice relied on.

• Make sure all pages are legible and complete.

Step 3: Organize the Packet

A clear order helps reviewers find key documents. A common order is:

• Cover letter or index.

• Election statement, addendum, and attending physician documentation.

• Certifications and recertifications with narratives.

• Face-to-face encounter documentation and attestations.

• Referral and admission records.

• Plan of care and interdisciplinary group notes.

• Physician orders.

• Visit notes by discipline, in date order.

• Medication records.

• Level of care documentation.

• Discharge or revocation documentation.

• Signature logs and attestations.

Step 4: Conduct a Pre-Submission Review

Before submitting, a qualified reviewer should check:

• Every requested item is included.

• The election statement and certifications meet regulatory requirements.

• Narratives are present, individualized, correctly placed, and attested.

• Face-to-face encounters are timely and attested.

• Dates of service are fully covered by valid documentation.

• Signatures are present and legible or supported.

• No documents have been altered or created after the fact.

Step 5: Consider a Cover Summary

A short cover letter can identify where key documents appear and briefly summarize how the record supports eligibility. It should be accurate and should not replace the medical record.

Step 6: Submit on Time

• Submit well before the deadline using the method the UPIC specifies, often electronic.

• Keep proof of submission and a complete copy of what was sent.

Step 7: Track Decisions

• Record each decision and denial reason.

• Analyze denials for patterns.

• Calendar appeal deadlines.

Making the Record Tell the Story

UPIC reviewers often review many records quickly. A well-organized packet helps them see eligibility clearly.

Show Eligibility at Admission

• Include the referral and hospital or physician records that describe the terminal diagnosis and decline before admission.

• Include the initial assessment with measurable findings, such as weight, intake, functional scales, and symptoms.

Show Continued Eligibility

• For each benefit period under review, include the recertification, narrative, and, for third and later periods, the face-to-face documentation.

• Include visit notes that show measurable indicators over time.

• Include interdisciplinary group notes that discuss eligibility.

Show Consistency

• Make sure nursing notes, aide notes, and physician narratives describe the same patient.

• Include explanations of any periods of stability.

Show the Level of Care

• For general inpatient or continuous home care days, include all documentation required to support each day.

Special Issues for Long-Stay Patients

UPIC reviews often focus on patients with long lengths of stay. For these patients:

• Include all benefit periods requested, not just the most recent.

• Highlight measurable decline across periods.

• Include face-to-face encounter documentation for every third and later period.

• Be prepared to explain periods of stability.

• Consider whether patients who no longer meet eligibility should be discharged.

Special Issues for Patients in Facilities

For patients in nursing facilities or assisted living facilities:

• Include facility records the hospice relied on, such as weights, intake, and medication records.

• Show the hospice's visits and services separately from facility care.

• Include the hospice's agreement with the facility, when requested.

Staffing the ADR Response

Prepayment review can generate many ADRs at once. Plan staffing:

• Designate an ADR coordinator and backup.

• Assign clinical reviewers for pre-submission checks.

• Assign medical records staff to assemble documents.

• Set internal deadlines well before the UPIC deadline.

• Track workload and adjust staffing as volume changes.

What Never to Do

• Never alter, backdate, or recreate documentation.

• Never add late entries without clearly labeling them as late entries with the actual date written.

• Never submit documents that you cannot authenticate.

• Never ignore an ADR.

Altered or backdated documents can turn a payment dispute into a criminal matter.

Common Reasons Hospice Claims Are Denied on UPIC Review

• Terminal prognosis not supported by the clinical record.

• Generic, missing, or improperly placed physician narratives.

• Late or missing face-to-face encounters or attestations.

• Election statements missing required elements or with invalid effective dates.

• Certifications signed late or by the wrong physician.

• Records showing stable or improving condition over long periods.

• Level of care not supported.

• Missing signatures.

• Incomplete submissions.

• No response to the ADR.

How UPIC Review Differs From MAC Review

Hospices familiar with MAC Targeted Probe and Educate reviews should understand key differences in UPIC reviews:

• Purpose. MAC reviews focus on payment accuracy and education. UPIC reviews focus on potential fraud, waste, and abuse.

• Deadlines. UPIC ADRs generally allow 30 days, compared with 45 days for MAC ADRs.

• Education. MAC TPE includes structured education sessions. UPIC reviews may not.

• Consequences. UPIC findings can lead to payment suspensions, extrapolated overpayments, revocation referrals, and law enforcement referrals.

• Scope. UPICs may request information beyond medical records and conduct interviews and site visits.

Because of these differences, hospices should treat UPIC reviews with a higher level of care and involve counsel.

What Reviewers Look For in Hospice Records

• A valid election statement and, where required, addendum.

• Timely certifications signed by the right physicians, with individualized narratives.

• Timely face-to-face encounters and complete attestations for third and later periods.

• Clinical documentation that supports a life expectancy of six months or less throughout each benefit period.

• Interdisciplinary group involvement and an individualized plan of care.

• Services consistent with the plan of care, including visits in the last days of life.

• Level of care support for general inpatient, continuous home care, and respite days.

• Proper documentation of live discharges and revocations.

Documenting Patient and Family Understanding

Some fraud cases have involved patients who did not know they were enrolled in hospice. UPIC reviewers may look for evidence that patients and families understood the election. Hospices can strengthen records by documenting:

• Conversations explaining hospice and the palliative nature of care.

• The patient's or representative's questions and responses.

• Family involvement in care planning.

• Communications with the attending physician.

Appeal Rights

UPIC prepayment denials are initial determinations. Hospices may appeal through the Medicare appeals process, starting with a redetermination. Hospices should:

• File appeals within the deadlines.

• Submit all evidence by the reconsideration level, because evidence not submitted to the Qualified Independent Contractor may be excluded at the administrative law judge level without good cause.

• Track appeal outcomes.

Managing Cash Flow on Prepayment Review

• Estimate how many claims will be held and for how long.

• Prioritize prompt, complete responses to speed payment.

• Maintain reserves or credit where possible.

• Communicate with vendors and contracted facilities.

Using the Review to Improve

• Analyze every denial for root causes.

• Provide education to physicians, nurses, and admissions staff.

• Strengthen pre-billing reviews of certifications and election statements.

• Audit long-stay patients and live discharges.

• Track improvements in approval rates.

When to Involve Counsel

Involve experienced healthcare counsel when:

• The hospice is placed on UPIC prepayment review.

• The UPIC requests information beyond medical records.

• The UPIC requests interviews or conducts site visits.

• The hospice receives a payment suspension notice.

• Denial rates remain high.

• There are any indications of an investigation.

A Hypothetical Example

A hospice in Texas receives a UPIC notice placing it on prepayment review for claims involving patients with stays over 180 days. It receives ADRs for 40 claims with 30-day deadlines. The hospice assigns an ADR coordinator, engages counsel, and builds a standardized packet order. A clinical reviewer checks each packet and finds that several narratives were copied across benefit periods and some face-to-face attestations were missing the statement that findings were provided to the certifying physician.

The hospice submits complete records on time, appeals denials where documentation supported eligibility, and retrains physicians and nurse practitioners. It also audits its long-stay population and discharges patients who no longer meet eligibility. Over the next several months, its approval rate improves and the UPIC removes it from prepayment review.

After Prepayment Review Ends

When a hospice is removed from prepayment review, it should:

• Confirm the removal in writing.

• Continue the documentation improvements made during the review.

• Monitor for postpayment reviews of claims from the same period.

• Keep appealing denials that remain open.

• Report lessons learned to leadership.

A UPIC ADR Response Checklist

• ADR logged on receipt with due date.

• Counsel notified.

• All requested items gathered.

• Election statement and addendum reviewed.

• Certifications, narratives, and face-to-face documents reviewed.

• Clinical records complete for all dates of service.

• Level of care documentation included.

• Signatures present or supported by logs or attestations.

• Packet organized with an index.

• Pre-submission review completed.

• Submitted before the deadline with proof of submission.

• Decision tracked and appeal deadline calendared.

A Hypothetical Packet Order for One Claim

For a 60-day benefit period in the fourth benefit period, a well-organized packet might include, in this order:

• An index listing each document and page range.

• The election statement and any addendum.

• The recertification for the period, with the narrative and attestation.

• The face-to-face encounter note and attestation.

• The prior benefit period's recertification, for comparison.

• The current plan of care and updates.

• Interdisciplinary group notes for the period.

• Physician orders.

• Visit notes by discipline, in date order.

• Medication profile and administration records.

• Signature log.

Questions to Ask Before Submitting Each Packet

• Does the packet include every item the ADR requested?

• Would a reviewer see a valid election and certification for every date of service?

• Does the clinical record show why this patient had a six-month prognosis?

• Are all signatures present and legible or supported?

• Is anything in the packet altered, recreated, or undated?

Staying Calm Under Review

Prepayment review is stressful, but it is also an opportunity to show reviewers that the hospice's care and documentation are sound. A steady, organized response helps.

Key Takeaways

• UPIC prepayment review holds payment until records are reviewed.

• UPIC ADRs generally have 30-day deadlines.

• Complete, organized, unaltered records are the best defense.

• Long-stay patients, live discharges, and certifications draw the most attention.

• Appeal incorrect denials and fix root causes.

• Involve counsel from the start.

Frequently Asked Questions

How long do hospices have to respond to a UPIC ADR?

CMS guidance generally provides 30 days for UPIC ADRs. Check each ADR for its deadline.

What happens if we do not respond?

The claim may be denied for failure to respond under 42 CFR 405.930.

Can UPIC prepayment denials be appealed?

Yes. They are initial determinations with full appeal rights.

How long does prepayment review last?

It varies. It may continue until the UPIC is satisfied with billing accuracy or takes other action.

Should we involve a lawyer?

Yes, especially because UPICs focus on fraud, waste, and abuse and may refer matters to law enforcement.

Conclusion

UPIC prepayment review is a serious event for any hospice, especially in the current enforcement environment. Hospices that log every ADR, assemble complete and well-organized records, review packets before submission, never alter documentation, appeal incorrect denials, address root causes, and involve counsel early will be best positioned to restore cash flow and demonstrate compliance.

How HealthBridge Can Help

HealthBridge is a healthcare management consulting firm that helps hospices respond to UPIC prepayment review by organizing ADR packets, conducting pre-submission reviews, analyzing denial patterns, supporting appeals, and training staff, working alongside legal counsel. If your hospice is on UPIC review or wants to prepare, please get in touch with us. We will be happy to help you with this topic.

References

• Electronic Code of Federal Regulations. 42 CFR 405.903, Prepayment Review. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-405/subpart-I/section-405.903

• Electronic Code of Federal Regulations. 42 CFR 405.930, Failure to Respond to Additional Documentation Requests. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-405/subpart-I/subject-group-ECFRba80b2c5e3f1227/section-405.930

• Electronic Code of Federal Regulations. 42 CFR Part 418, Subpart B (Election and Certification). https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-418/subpart-B

• Centers for Medicare & Medicaid Services. Additional Documentation Request. https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/medical-review-education/additional-documentation-request

• Centers for Medicare & Medicaid Services. Medicare Program Integrity Manual, Chapter 3, Verifying Potential Errors and Taking Corrective Actions. https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/pim83c03.pdf

• Centers for Medicare & Medicaid Services. Medicare Program Integrity Manual, Chapter 4, Program Integrity. https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/pim83c04.pdf

• Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual, Chapter 9, Coverage of Hospice Services Under Hospital Insurance. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c09.pdf

• Centers for Medicare & Medicaid Services. CMS Announces Aggressive Nationwide Crackdown on Fraud with Six-Month Hospice and Home Health Agency Enrollment Moratoria (May 13, 2026). https://www.cms.gov/newsroom/press-releases/cms-announces-aggressive-nationwide-crackdown-fraud-six-month-hospice-home-health-agency-enrollment

• Federal Register. Medicare Program; FY 2027 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Program Requirements (August 3, 2026). https://www.federalregister.gov/documents/2026/08/03/2026-15686/medicare-program-fy-2027-hospice-wage-index-and-payment-rate-update-and-hospice-quality-reporting