UPIC
Unified Program Integrity Contractors. The most aggressive Medicare and Medicaid reviewers: unannounced records requests, payment suspensions, and fraud referrals sit in their toolkit.
Services · Payor Audit Readiness
Payor audits are won
before the letter arrives.
UPIC, RAC, TPE, and commercial SIU teams pick their targets from billing data you have already submitted. Adentris runs the audit they would run, on your charts, first: defensibility scored against every billed code, extrapolation exposure quantified, and an ADR response playbook your team can execute under a 30-day deadline.
Mock ADR chart sampling Extrapolation exposure quantified BH / SUD specialty depth
Who is auditing
Six review programs. One question behind all of them.
Does the documentation support what you billed? Every program below answers it differently, but that is the only question on the table.
RAC
Recovery Audit Contractors, paid a percentage of what they claw back. Post-payment data mining across three years of claims, with an incentive structure to find problems.
TPE
Targeted Probe and Educate. Three rounds of 20 to 40 claims each. Fail all three and the file moves to extrapolation, prepayment review, or referral.
MAC prepayment review
Claims held before payment until documentation is reviewed. Cash flow stops while the review runs. Getting off prepayment status takes sustained clean submissions.
Commercial SIU
Special Investigations Units at commercial payors and MCOs. Data mining plus complaint-driven reviews, with recoupment demands and network termination as levers.
Payment integrity vendors
Third-party firms auditing on the payor's behalf, paid to find variance. High-volume, algorithm-selected chart requests that arrive with short deadlines.
How it escalates
A routine records request becomes
a seven-figure problem in five steps.
Most providers lose payor audits on process, not on care quality. The pattern is predictable, which is exactly why it is preventable.
- 01The ADR arrives with a 30-45 day clockAdditional Documentation Request for 20 to 40 charts. The deadline is real: late or missing responses become automatic denials.
- 02The sample fails on documentation, not careMissing time documentation, weak medical necessity, plans that do not match billed services, absent signatures.
- 03The error rate gets extrapolatedA 40 percent error rate on 30 charts is applied statistically to three years of claims. The recoupment demand is now measured in millions.
- 04Prepayment review strangles cash flowEvery new claim is held for manual review before payment. Payroll does not wait for adjudication.
- 05Escalation: suspension or referralPayment suspension, network termination, or an OIG referral. At this point counsel leads and options have narrowed.
Assessment scope
We run the audit they would run. Then fix what it finds.
Mock ADR chart sampling
30 to 60 charts selected the way auditors select them: highest-volume codes, outlier patterns, highest-dollar service lines, and the payors most active against your specialty.
Defensibility scoring per claim
Each sampled claim scored against its documentation: medical necessity, level-of-care support, signatures and credentials, time documentation, and template compliance.
Golden thread review
Assessment to treatment plan to progress note to claim. Auditors follow that thread; we verify it holds for every sampled encounter.
Extrapolation exposure model
Your sampled error rate projected across the claims universe, the same math a UPIC uses. Leadership sees the real number before an auditor computes it.
ADR response playbook
Who owns the response, how evidence packages get assembled, which deadlines govern, and what a complete submission looks like. Written for the day the letter arrives.
Staff tabletop
A dry run with your billing, clinical, and compliance leads on a realistic audit scenario, so the first real ADR is not the first rehearsal.
Deliverables
What lands on your desk.
- Defensibility score by service line and payor. Where the documentation holds, where it folds, and which codes carry the exposure.
- Findings register with chart citations. Every failure tied to the specific chart, the billed code, and the rule or policy it fails against.
- Extrapolation exposure estimate. Conservative, expected, and worst-case recoupment ranges if an auditor ran the same sample.
- ADR response playbook and remediation plan. The response process for the next letter, plus the documentation fixes that shrink the next sample's error rate.
Process
Four steps, two weeks to first findings.
- 01Scope call. Payor mix, service lines, audit history, active letters if any, and the codes that worry your billing team.
- 02Sample selection. Claims data drives an auditor-realistic sample. You pull the charts; we work under BAA with secure transfer.
- 03Mock audit. The Adentris rule engine plus analyst review scores every sampled claim, the same pass a real reviewer would make.
- 04Report, playbook, tabletop. Findings walkthrough with leadership, the ADR playbook handoff, and a staff dry run.
The same engine that reviews charts in production runs your mock audit.
Adentris reviews live charts continuously for multi-site behavioral health networks through Documentation Compliance. That engine, pointed at your sample, is why findings arrive in weeks with chart-level citations. And it is why readiness does not have to expire when the report is delivered: the audit converts to continuous review, so the next sample an auditor pulls is one your own system already checked.
01 Which audit types does this prepare us for?
Medicare-side reviews (UPIC, RAC, TPE, MAC prepayment and postpayment, SMRC) and the commercial side: MCO payment integrity vendors and SIU investigations. The mechanics differ; the defense is the same: documentation that stands behind every billed code.
02 How many charts do you sample?
Typically 30 to 60 per engagement, weighted the way auditors weight them: your highest-volume codes, your outlier patterns, your highest-dollar service lines, and the payors most active in your region. The sample mirrors a real ADR, not a random pull.
03 Do you cover behavioral health and SUD specifics?
It is our deepest specialty. Level-of-care defensibility against ASAM criteria, golden thread from assessment to plan to note to claim, time-based code documentation, group note individualization, and the H-code patterns that draw BH audit attention.
04 Can you help during an active audit?
Yes. If an ADR or audit letter is already on your desk, we switch to response mode: evidence package assembly, chart-by-chart defensibility review, deadline management, and appeal support. Tell us the deadline on the scope call.
05 How long does the assessment take?
First findings inside two weeks of receiving the chart sample and claims data. The full report, playbook, and staff tabletop complete within four weeks for a typical multi-site provider.
06 Is this legal advice?
No. It is a documentation and billing defensibility assessment designed to work alongside your counsel. When an audit escalates toward suspension or referral, your attorney leads and our findings become their evidence base.
Run the audit on your terms. Before someone else runs it on theirs.
One scope call, one chart sample, two weeks to a defensibility score your CFO and your counsel can both use.