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Healthcare upcoding

Healthcare upcoding

Healthcare upcoding

In this situation, the doctor is not criminally liable. The doctor is not criminally liable if the court can show that she was unaware of what the medical assistant was doing. The medical assistant will face charges of upcoding and medical fraud. If there is no proof that the doctor was unaware, she can be accused of upcoding.

Upcoding is the practice of healthcare professionals submitting erroneous billing codes to public insurers to increase reimbursement. The doctor claims that the patient underwent more expensive and involved operations than those done.

Among the punishments for such a crime are:

  • Paying any penalty incurred.
  • Being incarcerated.
  • Losing even one’s working license.

After an audit, if the healthcare provider can demonstrate that the billed operations were performed or that the upcoding was accidentally made, an attorney can support their position.


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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