UPIC and MAC Wound Care Audits
Responding to Unified Program Integrity Contractor and MAC document requests targeting debridement and skin substitute claims.
Is Your Wound Care Practice Under Medicare Audit or Investigation?
Speak with healthcare attorneys defending wound care providers in UPIC audits, skin substitute reviews, payment suspensions, extrapolated overpayment demands, False Claims Act investigations and OIG matters.
Response and appeal deadlines may be extremely short. Contact the firm as soon as possible after receiving a notice.
- Representing wound care providers nationwide
- More than 15 years defending healthcare providers
- Audits, appeals, suspensions and FCA matters
- Confidential consultation
Recognize the shift
A Wound Care Audit Rarely Announces That It Has Become a Fraud Case
It usually begins as a records request: a sample of skin substitute or debridement claims flagged for missing documentation. The signals that a payment review has moved into a False Claims Act investigation are specific and recognizable.
01
A civil investigative demand arrives while a MAC or UPIC review is still open.
02
A payment suspension cites a credible allegation of fraud rather than a routine overpayment.
03
An extrapolated demand reaches years beyond the claims actually sampled.
04
Document requests move past the flagged claims to distributor, sales rep or physician relationships.
Where the Firm Can Help
Calhoun Bhella LLP represents wound care clinics, mobile wound care groups, physician practices, suppliers and hospital-based programs.
Skin Substitute / CTP Billing Reviews
Defense of cellular and tissue-based product claims, including medical necessity, product selection and wastage documentation.
Medicare Payment Suspensions
Rebuttals to suspensions issued under 42 CFR 405.371 based on an alleged credible allegation of fraud.
Extrapolated Overpayment Demands
Challenging statistical sampling and extrapolation that projects a small claim sample across a multi-year lookback.
False Claims Act & Civil Investigative Demands
Representation when an audit is referred to the Department of Justice or a qui tam complaint is unsealed.
Anti-Kickback Statute Exposure
Review of distributor arrangements, sales representative compensation and referring physician relationships.
Do Not Ignore a Notice from a UPIC, CMS, the OIG or the DOJ.
Some notices allow only a limited period to submit a rebuttal, appeal or supporting documentation. Missing a deadline may significantly reduce the options available to a provider.
The Firm
Healthcare Attorneys Representing and Defending Providers
Calhoun Bhella LLP defends wound care providers facing Medicare audits, payment suspensions, enrollment actions, overpayment demands and government investigations. The firm helps providers understand the allegations, preserve their appeal rights and prepare an appropriate legal response.
- The firm represents wound care providers across the United States.
- The attorneys understand Medicare coverage, billing and regulatory enforcement.
- The firm handles audits, appeals, revocations and payment suspensions.
- The firm understands the financial consequences of suspended Medicare payments.
What Happens After You Contact the Firm?
Step 1
Tell Us What Happened
Provide the notice type, date received and any known response deadline.
Step 2
Speak with a Wound Care Attorney
The firm reviews the situation and discusses the available legal options.
Step 3
Develop a Response Strategy
Where the firm accepts the matter, the attorneys can help prepare the response, rebuttal, appeal or defense strategy.
Wound Care Issues We Handle
- UPIC audits and investigations
- SMRC and TPE reviews
- Prepayment medical review
- Post-payment audits
- Additional documentation requests
- Debridement coding audits (CPT 11042–11047)
- Skin substitute and graft billing reviews
- Medical-necessity denials
- Statistical extrapolation challenges
- Overpayment appeals and ALJ hearings
- Medicare payment suspensions
- CMS enrollment revocations
- OIG investigations and subpoenas
- Civil investigative demands
- False Claims Act and qui tam defense
- Anti-Kickback and Stark analysis
- Corrective action planning
- Compliance program review
Request a Confidential Consultation
Tell us briefly about the notice, audit or enforcement action your wound care practice has received. Use the form above or call the firm directly.
(607) 391-2404Frequently Asked Questions
When does a wound care audit become a False Claims Act case?
Usually when the government stops testing coverage and starts building intent. A civil investigative demand, a suspension citing a credible allegation of fraud, an extrapolated demand far beyond the sample, or requests for emails and vendor agreements all signal the posture has changed.
Why are skin substitute claims drawing so much scrutiny?
Cellular and tissue-based product billing carries high per-claim value, and enforcement activity around amniotic and other graft products has increased sharply. Product selection, application frequency, wound measurement and wastage documentation are all common audit targets.
Can an extrapolated overpayment demand be challenged?
Often, yes. Sampling methodology, universe definition, the qualifications of the statistician and the underlying claim determinations can each be contested through the Medicare appeals process.
What should I do first after receiving a notice?
Calendar the deadline, preserve records without altering charts, limit internal discussion of the matter, and speak with healthcare defense counsel before producing documents. Deadlines can be very short.
Prior results do not guarantee a similar outcome. Every case is different and must be evaluated on its own facts. This page is attorney advertising and provides general information only, not legal advice.