Welcome back everybody after the holidays. As a CPA, I have always been uncomfortable when the word “Audit” is used to describe activity since the term audit comes with specific requirements as CPA.
That being said, let’s talk about the four audit worlds in healthcare and how it may impact you.
Purpose: Detect and investigate fraud, waste, and abuse in Medicare & Medicaid
Who they work for: The Centers for Medicare & Medicaid Services (CMS)
Who they target: Providers, suppliers, billing companies
What they do:
Key powers:
Tone: Investigative, adversarial
Translation: “We think something is wrong — prove us wrong.”
Purpose: Oversight, enforcement, and law enforcement support
Who they work for: Department of Health & Human Services
Who they target: Providers, vendors, states, CMS itself
What they do:
Key powers:
Tone: Law enforcement
Translation: “This could end in handcuffs or headlines.”
🔥 Important: UPICs often build the case → OIG prosecutes or escalates it.
Purpose: Oversight of federal programs, not individual providers
Who they work for: Congress
Who they target: CMS, HHS, states, federal programs
What they do:
What they do not do:
Tone: Analytical, policy-focused
Translation: “Is the system working the way Congress intended?”
GAO findings often change policy, not prosecute providers.
There is no standing federal audit authority called DOGE that:
What people call “DOGE audits” were:
Key point: DOGE could not ignore UPICs — and UPICs never answered to DOGE.
| Entity | Targets Providers? | Recoups Money? | Refers to DOJ? | Changes Policy? |
| UPIC | ✅ Yes | ✅ Yes | ✅ Yes | ❌ No |
| OIG | ✅ Yes | ✅ Yes | ✅ Yes | ⚠️ Sometimes |
| GAO | ❌ No | ❌ No | ❌ No | ✅ Yes |
| “DOGE” | ❌ No | ❌ No | ❌ No | ❌ No |
Last month, the medical staff at a Twin Cities hospital were treating a patient for a traumatic head injury. The patient was brought in by
As of Jan. 1, the Centers for Medicare & Medicaid Services (CMS) initiated a three-year phase-out of the Inpatient-Only (IPO) List, which fundamentally reshapes how
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