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Lowther | Walker is a national leader in unbundling fraud defense for medical providers. We defend surgeons, laboratories, and hospital networks accused of fragmenting services, turning potential criminal liabilities back into civil administrative disputes.
Don’t let a Medicare billing mistake cost you your practice, your license, and your freedom. Call Lowther | Walker for urgent legal guidance when facing unbundling fraud charges.
No-obligation. Fully confidential.
Call Us Today: (404) 496-4052
Lowther | Walker deploys a team of veteran federal defense attorneys to protect healthcare providers from aggressive unbundling investigations launched by the Department of Justice (DOJ), Office of Inspector General (OIG), and Centers for Medicare & Medicaid Services (CMS).
We guide medical providers in the following:
We act as your immediate firewall against Unified Program Integrity Contractors (UPICs), Recovery Audit Contractors (RACs), and Medicare Administrative Contractors (MACs). By strictly directing all agent inquiries and document requests through our legal team, we insulate you from high-pressure interviews, ensuring that no statements are made that could be twisted into an admission of guilt.
We do not wait for the government to tell us what they found. Our team conducts a preemptive, comprehensive analysis of your CPT and HCPCS usage against National Correct Coding Initiative (NCCI) edits. We identify the specific claims triggering the investigation and secure the necessary operative reports to justify the distinct procedural services before the prosecution can seize them.
Our primary goal is to resolve the matter before it reaches a courtroom. We engage federal prosecutors early to reframe the narrative, utilizing our findings to support the downgrading of potential False Claims Act charges. We fight to keep the resolution within the civil or administrative realm, protecting your medical license and freedom.
We vigorously challenge the assertion that billing errors equate to fraud. We build a defense demonstrating that “unbundling” was caused by ambiguous Modifier 59 guidelines, automated prompts within your EHR software, or legitimate differences in clinical interpretation—not a willful scheme to defraud federal healthcare programs.
The government often relies on flawed sampling to estimate damages. We counter this by deploying independent Certified Professional Coders (CPCs) and statistical experts to challenge their extrapolation methods. We scientifically validate the medical necessity of your separate procedures, dismantling the government’s calculation of financial loss.
Investigation terminated; no prosecution. DOJ notified our client, the CEO of a major hospital network, that he was the target of a multi-million-dollar healthcare fraud investigation related to “Medicare upcoding” that the FBI and HHS-OIG […]
The FBI and the HHS-OIG investigated our client for Health Care Fraud based on the client’s submitting over $7 million in alleged false claims to Medicare. The Government indicted our client on Conspiracy to commit […]
HHS-OIG investigated our client for Healthcare Fraud and Aggravated Identity Theft based on the client’s allegedly participating in a “telemedicine” kickback scheme that defrauded Medicare of approximately $30 million in reimbursements for not-medically-necessary durable medical […]
A private insurance company discovered that our client, a dentist, fraudulently billed it, various other insurance companies, and federal health care benefit programs for approximately $400,000 of services that our client did not provide. We […]
The Department of Justice’s Criminal Division, Fraud Section charged our client and nine other individuals in a $1.4 Billion health care fraud, wire fraud, and money laundering conspiracy (the largest health care fraud case that […]
Investigation terminated; no prosecution. DOJ notified our client, the CEO of a major hospital network, that he was the target of a multi-million-dollar healthcare fraud investigation related to “Medicare upcoding” that the FBI and HHS-OIG […]
The FBI and the HHS-OIG investigated our client for Health Care Fraud based on the client’s submitting over $7 million in alleged false claims to Medicare. The Government indicted our client on Conspiracy to commit […]
HHS-OIG investigated our client for Healthcare Fraud and Aggravated Identity Theft based on the client’s allegedly participating in a “telemedicine” kickback scheme that defrauded Medicare of approximately $30 million in reimbursements for not-medically-necessary durable medical […]
A private insurance company discovered that our client, a dentist, fraudulently billed it, various other insurance companies, and federal health care benefit programs for approximately $400,000 of services that our client did not provide. We […]
The Department of Justice’s Criminal Division, Fraud Section charged our client and nine other individuals in a $1.4 Billion health care fraud, wire fraud, and money laundering conspiracy (the largest health care fraud case that […]
Unbundling (also known as fragmentation) occurs when a provider uses multiple CPT codes for parts of a procedure covered by a single, comprehensive code.
Federal agents treat unbundling as a “scheme to defraud” under 18 U.S.C. § 1347. The government builds these cases by alleging you manipulated the billing system to bypass the National Correct Coding Initiative (NCCI) edits. When you’re facing government interest in your billing practices, you require urgent guidance from the experienced unbundling defense attorneys at the Lowther | Walker law firm.
Lowther Walker defends against all forms of fragmentation allegations:
Federal prosecutors frequently target high-volume surgical practices, particularly in orthopedics and cardiovascular surgery, alleging that providers are improperly fragmenting the global surgical package. In these cases, the government claims that standard components of a single surgery, such as the initial incision, the primary repair, and the final closure, were billed as separate line items to inflate reimbursement.
A common example involves billing for a bone graft harvest or laminectomy separately when it is inherently included in the primary spinal fusion code. Our defense strategy focuses on dissecting the operative report to prove that the disputed services required significantly more time, effort, or distinct anatomical access than the global code allows, justifying separate reimbursement.
The Office of Inspector General (OIG) aggressively monitors laboratories for panel explosion schemes in which automated chemical analyzers are used to separate standard panel tests. The government argues that a provider billed for individual component assays, such as Creatinine, Sodium, or Glucose, rather than the appropriate, lower-reimbursed Comprehensive Metabolic Panel (CMP) or Basic Metabolic Panel (BMP).
We defend against these allegations by demonstrating that the individual tests were medically necessary for the specific patient’s condition and that the ordering physician did not intend to order the bundled panel, or that the specific combination of tests did not actually meet the strict definition of a panel under CMS guidelines.
Modifier 59 is the most audited in the American healthcare system. Government auditors often flag high usage of this modifier as “cookie-cutter” fraud, alleging it is being used solely to bypass National Correct Coding Initiative (NCCI) edits rather than to indicate a genuinely separate service.
Our defense relies on clinical specificity. We work to prove that the procedure in question was, in fact, distinct, involving a different anatomical site, a separate incision, or a completely different patient encounter on the same day, thereby validating the use of the modifier and refuting the government’s claim of abuse.
Upcoding via fragmentation occurs when a provider breaks a single comprehensive service into multiple smaller component codes, resulting in a total reimbursement that exceeds what the appropriate high-level code would pay. This practice triggers immediate red flags in CMS claims processing software, which is designed to detect payment spikes associated with code splitting. We counter these accusations by analyzing the complexity of the care provided.
We aim to show that the patient’s unique presentation required a deviation from the standard comprehensive code, and that the fragmented billing accurately reflected the increased resources and clinical decision-making required, rather than an intentional scheme to inflate revenue.
When you are accused of unbundling, you face repayment penalties and the potential loss of your license. Our defense strategy focuses on negating criminal intent.
Many providers believe unbundling is a civil matter that can be fixed with a refund. This is a dangerous misconception. Once the DOJ or FBI is involved, the penalties are punitive, not just restorative.
If you receive a Target Letter, a Civil Investigative Demand, or an OIG subpoena regarding your billing codes:
DO NOT contact the auditor to “explain” the situation. Statements like “we were just trying to cover our costs” can be used as admissions of intent.
DO NOT alter or “fix” past charts. This is an obstruction of Justice and is often easier to prove than the fraud itself.
DO impose a litigation hold on all billing software, emails, and patient records.
DO contact Lowther | Walker for a shadow audit. We review your data under the attorney-client privilege before the government sees it.
Conviction, or certain civil settlements, can lead to mandatory exclusion from Medicare and Medicaid for at least 5 years.
Unbundling falls under the False Claims Act (FCA). In FCA cases, the government does not just ask for the overpayment back. They demand three times (3x) the amount of the error, plus penalties of up to $27,000 per invoice.
If prosecutors can prove the unbundling was intentional, you face up to 10 years in federal prison per count of healthcare fraud.
Federal agencies are aggressively using data analytics to flag providers for unbundling schemes. If your billing patterns have triggered an investigation, your entire healthcare career is on the line. Lowther | Walker is dedicated to shielding your practice from these specific allegations, using our background in provider defense to dismantle the government’s case. Proactive defense is your strongest asset; contact us before an indictment is handed down.
Call us immediately at (404) 806-7997 to speak with an experienced unbundling defense attorney.
No-obligation. Fully confidential.
Call Us Today: (404) 496-4052
Upcoding is billing for a more expensive service than the one you actually performed. Unbundling is breaking a single comprehensive procedure into multiple component codes to illegally increase your payment
Yes, you are legally responsible for every claim submitted under your NPI. However, we can use software errors as a defense to prove you did not have “criminal intent” to deceive the government.
Do not answer their questions. You are not required to speak to them without an attorney present, even if they claim they “just want to clear a few things up.” Ask for their business cards, politely state that your attorney will contact them, and ask them to leave. Then, call Lowther | Walker immediately. Anything you say during that initial surprise visit can be used to build the indictment against you.
An investigation alone does not automatically revoke your license, but an indictment or conviction can trigger immediate suspension or revocation by your state medical board. Furthermore, a conviction (or even certain civil settlements) can lead to mandatory exclusion from Medicare/Medicaid (OIG Exclusion), which effectively ends most medical careers. Our goal is to resolve the case in a way that preserves your ability to practice medicine.
Yes. In healthcare fraud cases, the government often uses civil or criminal forfeiture to freeze personal and business assets it believes are “proceeds of fraud” before you are convicted. We have extensive experience contesting these seizures to release funds for your defense and business operations.
Likely, yes. Lowther | Walker has defended clients in some of the largest healthcare fraud prosecutions in U.S. history. Notably, we represented a client in United States v. J.P., et al., a $1.4 billion healthcare fraud conspiracy, the largest ever prosecuted by the DOJ at that time. We secured a mistrial after a six-week trial and, upon retrial, a full acquittal (Not Guilty on all counts) for our client.
Yes, this is our primary goal. We frequently intervene during the “pre-indictment” phase. For example, we represented a chiropractor investigated for $3.5 million in billing fraud. By conducting our own independent investigation and presenting our findings to prosecutors, we convinced the government to terminate the criminal investigation entirely and resolve the matter with a civil settlement, keeping our client out of prison and off the criminal docket.
Healthcare defense requires specific knowledge of medical coding, billing regulations, and federal administrative law that general criminal lawyers lack. Joshua Sabert Lowther, Esq. is a nationally recognized trial and appellate advocate who has secured acquittals and dismissals in federal courts across the country. Murdoch Walker, II, Esq. brings a unique perspective as a former investigator and Task Force Officer. He understands exactly how federal agents build their cases, allowing us to dismantle them from the inside out.
Yes. You cannot outsource criminal liability. Federal prosecutors often use the theory of “deliberate ignorance” or “willful blindness” to charge physicians. This means that if you signed the claims, or if the government believes you should have known that the billing was improper (for example, if the revenue was suspiciously high), they can charge you as if you personally manipulated the codes. We defend against this by demonstrating that you relied in good faith on hired professionals and that there was no criminal intent to defraud.
These are known as Qui Tam lawsuits under the False Claims Act. A whistleblower (often a former employee) files a lawsuit under seal, meaning it remains secret while the Department of Justice investigates you, to decide if they will join the case. If the government intervenes, the case can easily shift from a civil lawsuit to a criminal indictment. If you suspect an employee has filed a complaint, or if one is threatening to, you must engage counsel immediately to conduct an internal audit and prepare a defense before the government strikes.
