If you’re under investigation by OIG-HHS for upcoding, you have a limited time to respond to the allegations and protect your healthcare practice. Lowther | Walker stands as a premier national defense firm for healthcare providers under investigation for upcoding.
Our attorneys blend deep proficiency in Medicare billing regulations with a tactical understanding of government prosecution strategies. giving you a defensible path back to professional and financial security.
Contact Lowther | Walker for your confidential upcoding case review.
No-obligation. Fully confidential.
Call our federal law offices directly at 877-208-7146 with your upcoding defense questions.
Upcoding is a federal crime under the False Claims Act, which makes it illegal for a provider to knowingly submit fraudulent billing claims to government healthcare programs, such as Medicare or Medicaid, or private insurance programs. Upcoding occurs when a provider submits claims for reimbursement at a higher rate than warranted, either by exaggerating the complexity, time, or resources involved in patient services.
Submitting up-coded claims can trigger audits, False Claims Act investigations, and serious healthcare fraud charges.
A doctor may face allegations of upcoding for billing for a complex surgical procedure (e.g., a “complex repair” requiring layered closure) when only a simpler one (e.g., “simple repair” with surface closure) was completed
Using a more severe diagnosis code to justify a higher level of reimbursement can lead to professionals facing upcoding and fraud charges. Examples include coding a routine office visit as “complicated” or categorizing mild hypertension as severe to support billing for a higher-paying service.
Upcoding charges often follow when patient’s ED visit is coded at the highest level (Level 5), implying the most complex care, when the patient’s condition and treatment only warranted a lower level (e.g., Level 3). This often involves overstating the complexity of medical decision-making or the severity of the patient’s illness.
Billing for a comprehensive visit for an established patient when only a brief follow-up was conducted is another common act leading to upcoding allegations. For instance, charging for a 45-minute comprehensive examination when a 15-minute routine check-up was performed.
Our attorneys are masters in interpreting complex coding and billing standards. We scrutinize each claim to ensure your coding decisions match the actual services rendered.
With former task force, federal prosecutor, and investigator backgrounds on our team, we anticipate and counter prosecution strategies effectively.
Available 24/7, our team responds immediately to upcoding audits or investigations, no matter where you’re located.
Arguing that the higher-level codes were justified based on the provider’s clinical documentation and professional medical judgment. The defense maintains that the complexity of the patient’s condition, comorbidities, or risk factors warranted the level of service billed, even if it appears routine to auditors.
Claiming that the coding was based on a reasonable interpretation of complex or ambiguous coding guidelines. Since medical coding rules can be intricate and sometimes unclear, the defense argues that multiple reasonable interpretations exist and the provider chose one in good faith.
Asserting that any overbilling was unintentional and resulted from honest mistakes, inadequate training, or misunderstanding of coding requirements rather than deliberate fraud. This defense emphasizes the absence of criminal intent to defraud.
Blaming electronic health record (EHR) systems, billing software, or automated coding systems for generating incorrect codes. The defense argues that technological failures or default settings led to inappropriate upcoding without the provider’s knowledge or intent.
Demonstrating that the services provided met the appropriate standard of care and were medically necessary based on the patient’s presenting symptoms, medical history, and clinical presentation at the time of service. This defense focuses on justifying why the higher level of service was appropriate given the circumstances.
These defenses often involve presenting expert testimony, detailed medical record analysis, and evidence of the provider’s good faith efforts to comply with billing regulations.
Attorneys with Decades of Upcoding Defense Experience are a Free Phone Call Away. Call (404) 806-7997.
If you’ve received notice you’re facing an HHS audit or investigation related to billing fraud, contact Lowther | Walker for an immediate, confidential consultation with a seasoned healthcare fraud defense attorney. Call (404) 806-7997 or request a consultation online now.
No-obligation. Fully confidential.
Call upon decades of experience in healthcare compliance and healthcare law. From medical license defense to building billing structures that comply with DEA and Medicare guidelines, Lowther | Walker’s healthcare defense team leads the industry.
