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Healthcare upcoding

Healthcare upcoding

Healthcare upcoding

The physician has no criminal liability in this case. If the court can prove that the physician was unaware of what her medical assistant was doing, she is under no criminal liability. The medical assistant will be charged with medical fraud of upcoding. However, if there is no evidence that the physician was unaware, she could be charged with upcoding.

Upcoding is when healthcare providers submit false billing codes to government insurers to gain a higher reimbursement. The medical provider indicates that the patient undertook procedures that were more costly and complex than the actual procedures.

Penalties for such a crime include:

  • Paying fines imposed on them.
  • Serving jail time.
  • Even losing the working license.

After an audit, if the healthcare provider can prove that the provider performed the billed procedures or that the upcoding was unintentionally mistaken, an attorney can help their case.


Bauder, R., Khoshgoftaar, T. M., & Seliya, N. (2017). A survey on the state of healthcare upcoding fraud analysis and detection. Health Services and Outcomes Research Methodology17(1), 31-55.

Geruso, M., & Layton, T. (2020). Upcoding: Evidence from Medicare on squishy risk adjustment. Journal of Political Economy128(3), 984-1026.


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 Ethical and Legal Issues in Health Care 

Discussion Topic

Before starting this forum, please review the following:

Healthcare upcoding

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Unbeknownst to a physician in private practice, her medical assistant has been falsifying ICD-10-CM and CPT codes to ensure a greater reimbursement from insurers (including the federal government for Medicare) and has been pocketing the difference.

The Federal Office of the Inspector General conducts an audit based on a tip from a former employee and uncovers the scheme.

What, if any, is the physician’s criminal liability in this case? Why? Please note any regulations or court decisions that support your point of view.

At least 250 words.

APA Format.

Chapter 4-

 Required Textbook: Pozgar, G. (2021) “Legal and Ethical Essentials of Health Care Administration”, 3rdEdition, Burlington, MA: Jones & BartlettISBN: 978-1-284221794 or EBook: 978-1284055726

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