UPIC Prepayment Review for Hospice and Home Health: What It Is and How to Respond

Hospice and home health agencies are under intense federal scrutiny. In May 2026, CMS implemented nationwide six-month moratoria on new Medicare enrollment of hospices and home health agencies, citing a significant potential for fraud, waste, and abuse. CMS has also reported suspending payments to approximately 800 hospices and home health agencies suspected of fraud in Los Angeles, and its Fraud Defense Operations Center reported more than $23 million in suspended payments to suspect hospice providers in the first half of 2026.

In this environment, many hospice and home health agencies are encountering prepayment review conducted by Unified Program Integrity Contractors, or UPICs. UPIC prepayment review means that claims are held and reviewed before payment, often requiring the agency to submit medical records for each claim selected. It can significantly affect cash flow and may be part of a broader program integrity investigation.

This article explains what UPIC prepayment review is, how it differs from other reviews, why hospice and home health agencies are selected, what documentation reviewers look for, how to respond, and how to work toward ending prepayment review. It is educational and not legal advice. Agencies facing UPIC prepayment review should consider involving experienced legal counsel.

What Is UPIC Prepayment Review?

UPICs and Their Role

CMS describes UPICs as contractors that perform fraud, waste, and abuse detection, deterrence, and prevention activities for Medicare and Medicaid, including activities related to home health and hospice. UPICs operate in five geographic jurisdictions across the United States.

Prepayment Review Basics

The Medicare Program Integrity Manual, Chapter 3, explains that prepayment review occurs when a reviewer makes a claim determination before payment is made, and that prepayment review always results in an initial determination. Under CMS instructions:

• UPICs must notify selected providers before beginning a provider-specific review by sending an individual written notice indicating whether the review will be prepayment or postpayment.

• UPICs may request additional documentation for claims selected for review.

• If no response is received within the expected timeframe during prepayment review, the claim is denied in accordance with 42 CFR 405.903 and 405.930.

• Under CMS instructions, when a UPIC receives requested documentation for prepayment review, it makes a determination and notifies the MAC within the timeframes in the Program Integrity Manual, generally within 60 calendar days of receiving the documentation.

Limited vs. 100 Percent Prepayment Review

CMS manuals describe different levels of UPIC prepayment review:

• Limited or targeted prepayment review. CMS's Program Integrity Manual describes prepayment medical reviews associated with a limited claim count, such as 25 to 50 claims, or targeted review of specific codes. CMS has also recommended that UPIC prepayment review be limited to specific procedure codes, a specific number of claims, or a particular subset of beneficiaries identified through analysis, and that a probe sample of 20 to 40 claims may be used to validate data analysis or an allegation.

• 100 percent prepayment review. CMS instructions state that no UPIC shall initiate 100 percent prepayment review without CMS approval. Requests for 100 percent prepayment review are discussed at CMS case coordination meetings, and the request must include information such as background on attempts to educate the provider, the provider's historical improper payment rate, the expected length of review, and the criteria for removing the provider from 100 percent prepayment review.

How UPIC Prepayment Review Differs From MAC Review

MAC prepayment review, including Targeted Probe and Educate, focuses on compliance with coverage, coding, and payment rules and includes structured education. UPIC prepayment review is part of a program integrity function focused on fraud, waste, and abuse. UPIC medical review may also look for signs of documentation alteration, services not rendered, and other indicators of potential fraud. UPIC prepayment review may be used alongside other actions, such as investigations, interviews, site visits, and possible payment suspension or revocation recommendations.

Prepayment Review and Payment Suspensions

UPIC prepayment review is different from a payment suspension, although both affect cash flow. During a payment suspension, payments are withheld on claims while an investigation proceeds. CMS's Program Integrity Manual explains that UPICs are not required to perform 100 percent prepayment review during a payment suspension, but if prepayment review is not conducted, a postpayment review is performed on the universe of claims adjudicated during the suspension before an overpayment is determined. The manual also states that when a suspension is terminated, UPICs may consider other actions, such as education, prepayment review, revocation, or a new suspension, if they believe problems will continue.

Why Hospice and Home Health Agencies Are Selected

UPICs use data analysis, complaints, referrals, and other information to identify agencies for review. Based on CMS program integrity materials and moratorium notices, factors that may contribute to selection include:

• Rapid growth in claims or revenue, especially for newly enrolled agencies.

• Unusual patient patterns, such as long hospice lengths of stay, high live discharge rates, or patients who do not appear to meet eligibility criteria.

• Concentrations of referrals from a small number of physicians.

• Patients located far from the agency's service area.

• Billing that exceeds the agency's apparent staffing capacity.

• Complaints from beneficiaries or family members.

• Referrals from MACs during Targeted Probe and Educate.

• Location in geographic areas CMS has identified as high risk.

• Ownership patterns or changes that raise concerns.

In its hospice moratorium notice, CMS described recent increases in hospice enrollment in certain states, including Arizona, California, Georgia, Nevada, and Texas. CMS has also described heightened oversight of newly enrolled hospices in states with elevated fraud risk, nationwide hospice site visits, and a new public hospice scoring system.

Documentation Requirements Reviewers Focus On

Hospice

UPIC and other reviewers commonly focus on whether documentation supports:

• Terminal prognosis. Documentation should support that the patient has a terminal illness with a life expectancy of six months or less if the illness runs its normal course.

• Certification and recertification. Required certifications of terminal illness should be timely, signed by the appropriate physicians, and include required narratives.

• Face-to-face encounters. Required face-to-face encounters for certain recertifications should be documented and timely. CMS has noted that the Consolidated Appropriations Act, 2026 restricts the use of telehealth for hospice face-to-face encounters in certain circumstances, including areas subject to a hospice enrollment moratorium and hospices subject to enhanced oversight.

• The election statement. The election statement should be complete and properly signed. CMS has announced that providing the hospice election statement addendum is becoming mandatory under a final rule published in August 2026, rather than only upon patient request.

• The plan of care. The interdisciplinary group's plan of care should be individualized and updated.

• Services provided. Visit notes should show that services were actually provided as billed, by qualified staff, and should reflect the patient's condition.

• Level of care. Documentation should support the level of care billed, such as general inpatient care or continuous home care.

Home Health

Reviewers commonly focus on:

• Homebound status. Documentation should show that the patient meets Medicare's homebound criteria.

• Need for skilled services. Documentation should support the need for intermittent skilled nursing or therapy services.

• Face-to-face encounter. The encounter should be performed by an allowed practitioner within the required timeframe and relate to the primary reason for home health services.

• Certification and plan of care. Certifications and plans of care should be signed by an appropriate physician or allowed practitioner. CMS's Program Integrity Manual instructs reviewers to consider plans of care and certifications only from physicians who do not have a financial relationship with the home health agency.

• Visit documentation. Visit notes should match the plan of care and show services were provided as billed.

• Medical necessity and coding. Documentation should support the diagnoses and other information used for payment.

Indicators of Potential Fraud

Because UPICs focus on program integrity, reviewers may also look for indicators such as obliterated sections, missing or inserted pages, white-out, excessive late entries, cloned documentation across patients, and services billed when patients were hospitalized or when staff were not working.

How to Respond to UPIC Prepayment Review

Step 1: Read the Notice Carefully

Identify whether the review is limited or 100 percent prepayment review, the services or codes affected, how claims will be selected, the documentation requested, and the response timeframe. CMS's Program Integrity Manual indicates that providers generally have 30 calendar days to respond to UPIC documentation requests, but always follow the timeframe in the request.

Step 2: Engage Counsel and Preserve Records

Because UPIC prepayment review may be part of a broader investigation, consider engaging experienced counsel. Issue a legal hold to preserve records, and never alter or backdate documents.

Step 3: Build a Prepayment Review Team

Include a coordinator to track ADRs and deadlines, clinical reviewers with hospice or home health expertise, records staff, billing staff, and the compliance officer.

Step 4: Create a Tracking System

Log every claim under review, the ADR date, the response deadline, the submission date, and the outcome. Track denial reasons and amounts.

Step 5: Submit Complete, High-Quality Records

For each claim, submit the full set of relevant documents, organized and indexed. For hospice, this typically includes the election statement and addendum as applicable, certifications and recertifications, face-to-face documentation, the plan of care, interdisciplinary group notes, visit notes, medication records, and documentation supporting prognosis. For home health, it typically includes the face-to-face encounter documentation, certification, plan of care, OASIS assessment, visit notes, and documentation supporting homebound status and skilled need.

Step 6: Conduct Quality Review Before Submission

Check each submission for completeness, signatures, dates, legibility, and patient identification. Use checklists based on hospice and home health coverage requirements.

Step 7: Analyze Results and Appeal When Appropriate

Prepayment denials are initial determinations that can be appealed through the Medicare fee-for-service appeals process, beginning with a redetermination request to the MAC, generally within 120 days. Appeal denials that you believe are incorrect, with supporting records that existed at the time of service.

Step 8: Fix Root Causes

Use denial patterns to identify and fix problems, such as weak prognosis documentation, missing face-to-face encounters, incomplete election statements, or insufficient homebound documentation. Implement training, template changes, and pre-billing review.

A Hospice Prepayment Review Checklist

Before submitting records for a hospice claim, confirm:

• The election statement is complete, signed, and dated, and the addendum requirements are met as applicable.

• Certifications and recertifications are timely, signed by the appropriate physicians, and include the required narrative.

• Required face-to-face encounters are documented and timely, and performed in a manner permitted under current rules.

• Clinical documentation supports a prognosis of six months or less, including disease progression, functional decline, and relevant measures.

• The interdisciplinary group plan of care is individualized and updated.

• Visit notes support each service and level of care billed.

• Signatures, dates, and credentials are present and legible.

A Home Health Prepayment Review Checklist

Before submitting records for a home health claim, confirm:

• The face-to-face encounter was performed by an allowed practitioner within the required timeframe and relates to the primary reason for home health care.

• The certification and plan of care are signed and dated by an appropriate physician or allowed practitioner without a financial relationship with the agency.

• Documentation clearly supports homebound status, including functional limitations and the effort required to leave home.

• Documentation supports the need for intermittent skilled services.

• The OASIS assessment is complete and consistent with clinical documentation.

• Visit notes match the plan of care in frequency and type of services.

• Signatures, dates, and credentials are present and legible.

A Hypothetical Example

Consider a home health agency that receives notice from its UPIC that a limited prepayment review will apply to 40 claims for new admissions. The agency engages counsel, issues a legal hold, and assigns a coordinator. It logs each ADR as it arrives and submits complete, indexed records well before each deadline.

The first results show that several claims were denied because the face-to-face encounter documentation did not clearly relate to the primary reason for home health services, and some plans of care were missing signatures. The agency files redetermination requests for denials where the original records did support coverage and implements an intake checklist, referral source education, and a pre-billing review for every new admission.

Over the following months, its denial rate on reviewed claims drops substantially. Through counsel, the agency provides the UPIC with a summary of its corrective actions and internal audit results. When the limited review concludes, the agency maintains its pre-billing review and quarterly audits.

Managing Cash Flow During Prepayment Review

Prepayment review delays payment on reviewed claims, and denials reduce revenue. Agencies can manage the impact by:

• Estimating the number of claims and dollars expected to be under review each month.

• Building a short-term cash forecast.

• Responding to ADRs early to speed determinations.

• Prioritizing documentation quality to reduce denials.

• Communicating with leadership and, if appropriate, lenders.

• Continuing to serve patients appropriately and planning for safe transitions if services must be reduced.

Working Toward Removal From Prepayment Review

CMS instructions require that requests for 100 percent prepayment review include criteria for removing the provider from review, and CMS manual instructions direct MACs to reassess providers on provider-specific prepayment review on a quarterly basis. While the specific criteria vary, agencies can position themselves for removal by:

• Demonstrating sustained improvement in documentation and denial rates.

• Responding completely and on time to every request.

• Documenting corrective actions, training, and internal audits.

• Communicating appropriately with the UPIC, often through counsel, about improvements.

• Maintaining accurate enrollment information and operational compliance.

Related Risks and Actions

Agencies under UPIC prepayment review should be aware of other possible actions:

• Payment suspension under 42 CFR 405.371, with a rebuttal opportunity under 42 CFR 405.374.

• Postpayment review and extrapolated overpayments.

• Revocation under 42 CFR 424.535, including for abuse of billing privileges.

• Non-billing deactivation. CMS began deactivating hospices that had not billed for six consecutive months in March 2024 and home health agencies in January 2026.

• Ownership restrictions. Under 42 CFR 424.550(b), hospices and home health agencies undergoing certain changes in majority ownership within 36 months of initial enrollment or the most recent such change must enroll as new providers, which the moratoria currently block.

• Referral to law enforcement.

Keeping Patient Care First

Prepayment review can create pressure to change admission or discharge decisions for financial reasons. Agencies should make clinical decisions based on patient needs and Medicare eligibility criteria, not on review status. Patients who meet hospice or home health eligibility should continue to receive appropriate care, and patients who no longer meet criteria should be discharged in accordance with Medicare rules and with appropriate planning. Clear, consistent clinical decision-making, documented in the record, is the best way to protect both patients and the agency.

Building Readiness Before a UPIC Notice Arrives

• Maintain an effective compliance program consistent with HHS-OIG's General Compliance Program Guidance and OIG's hospice and home health compliance guidance.

• Audit hospice eligibility, certifications, and election statements regularly.

• Audit home health homebound status, face-to-face encounters, and certifications regularly.

• Monitor PEPPER reports, which CMS has released for home health agencies and hospices, and internal data for outlier patterns.

• Review referral relationships and marketing practices.

• Keep enrollment information accurate, including managing employees such as hospice medical directors and administrators.

• Prepare for site visits.

Frequently Asked Questions

What is the difference between UPIC and MAC prepayment review?

MAC prepayment review, including TPE, focuses on compliance with coverage and payment rules and includes structured education. UPIC prepayment review is a program integrity action focused on fraud, waste, and abuse and may be part of a broader investigation.

Can a UPIC put my entire agency on 100 percent prepayment review?

CMS instructions state that UPICs may not initiate 100 percent prepayment review without CMS approval. Limited or targeted prepayment review may also be used.

How long does UPIC prepayment review last?

It varies. Requests for 100 percent prepayment review must include the expected length of review and criteria for removal. Improvement in documentation and denial rates is generally important.

What happens if I do not respond to a prepayment ADR?

The claim is denied under 42 CFR 405.903 and 405.930.

Can I appeal prepayment denials?

Yes. Prepayment review results in initial determinations that can be appealed, beginning with a redetermination request to the MAC.

Does UPIC prepayment review mean my agency will have its payments suspended?

Not necessarily. Prepayment review and payment suspension are different actions. However, both are tools UPICs may recommend, and agencies under prepayment review should be prepared for the possibility of other actions, especially if reviews reveal serious problems.

Conclusion

UPIC prepayment review is a significant program integrity action that can strain hospice and home health agencies financially and operationally, especially in the current environment of enrollment moratoria, payment suspensions, and heightened oversight. Agencies that respond quickly, engage counsel when appropriate, preserve records, submit complete and well-organized documentation, track results, appeal incorrect denials, fix root causes, and manage cash flow carefully are best positioned to resolve the review and protect their ability to serve patients.

How HealthBridge Can Help

HealthBridge is a healthcare management consulting firm that specializes in hospice and home health compliance, UPIC audit response, and documentation improvement. We help agencies organize and review records before submission, track prepayment review activity, analyze denial patterns, prepare appeals, strengthen eligibility and documentation practices, and build compliance programs that support sustained improvement. If your agency is facing UPIC prepayment review, please get in touch with us. We will be happy to help you with this topic.

References

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

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

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• Federal Register. Announcement of Nationwide Temporary Moratorium on Enrollment of Hospices (May 15, 2026). https://www.federalregister.gov/documents/2026/05/15/2026-09718/medicare-medicaid-and-childrens-health-insurance-programs-announcement-of-nationwide-temporary

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