Upcoding & Unbundling Fraud Defense Lawyer
Experienced Criminal Defense for Medical Billing Fraud Allegations
Healthcare providers in New York City are under increasing scrutiny from federal and state agencies for billing practices involving upcoding and unbundling. These allegations can quickly escalate into full-blown healthcare fraud investigations, putting your professional license, reputation, and freedom at risk. At Sosinsky Law, we provide aggressive, strategic legal defense for medical professionals and healthcare businesses accused of billing fraud—including complex cases involving CPT code manipulation, overbilling, and false claims.
Our firm has decades of experience representing physicians, billing managers, clinical directors, and executives in federal healthcare fraud cases. We understand the intricate rules governing Medicare and Medicaid billing, the investigative tools used by the Department of Justice (DOJ), and how to fight back against allegations of criminal intent.
If you’re being audited, investigated, or charged with upcoding or unbundling fraud, contact Sosinsky Law immediately. Early legal intervention can make a critical difference in how your case unfolds.
What Is Upcoding?
Upcoding occurs when a healthcare provider submits claims using billing codes for more complex or expensive services than those actually performed. In many cases, upcoding involves Current Procedural Terminology (CPT) codes or Healthcare Common Procedure Coding System (HCPCS) codes that exaggerate the level of service delivered.
Common examples of upcoding include:
- Billing for a 45-minute office visit when only a 15-minute consultation occurred
- Submitting claims for brand-name drugs when generic versions were provided
- Charging for multiple services when only one was rendered
- Reporting the use of specialized equipment or testing that was never utilized
- Listing procedures that were not medically necessary or even performed
While coding errors can occur unintentionally, the government often treats patterns of upcoding as intentional fraud, especially when high reimbursements or repeat discrepancies are involved.
What Is Unbundling?
Unbundling, also known as fragmentation, occurs when services that are supposed to be billed together under a comprehensive billing code are instead billed separately to generate higher reimbursement. Federal programs like Medicare require certain procedures to be grouped into a single payment under bundled billing rules. Examples of unbundling include:
- Separately billing for pre-operative and post-operative care instead of using a global surgery package code
- Breaking up a diagnostic panel into individual blood tests to increase payment
- Charging separately for facility fees and physician fees that should be billed as a unit
- Manipulating modifiers to avoid automatic code bundling
In both upcoding and unbundling cases, prosecutors often argue that the intent was to defraud Medicare, Medicaid, or private insurers, making these federal offenses punishable by prison, fines, and loss of licensure.
Who Is at Risk?
Any healthcare professional involved in coding, billing, or submitting claims to government health programs could be targeted in a fraud investigation. This includes:
- Physicians and physician groups
- Practice managers and billing supervisors
- Hospitals and outpatient clinics
- Ambulatory surgical centers (ASCs)
- Home healthcare agencies
- Mental health providers
- Chiropractors and physical therapists
- Medical coding and billing companies
Even unintentional errors can result in audits, overpayment demands, and criminal charges, especially if the government believes there’s a pattern of fraudulent billing activity.
Federal Agencies Involved in Billing Fraud Investigations
Upcoding and unbundling investigations are often triggered by:
- Whistleblower complaints (qui tam lawsuits)
- Data analytics audits flagging abnormal billing patterns
- Random or risk-based CMS audits
- Coordinated task forces, including the Medicare Fraud Strike Force
Investigations may involve the Department of Justice (DOJ), U.S. Attorney’s Office, Department of Health and Human Services Office of Inspector General (HHS-OIG), and the Federal Bureau of Investigation (FBI). These agencies have broad subpoena powers and can execute search warrants, seize records, and seek indictments.
If you’ve received a target letter, civil investigative demand (CID), subpoena, or audit notice, you should contact Sosinsky Law immediately before responding or speaking to investigators.
Potential Penalties for Upcoding and Unbundling Fraud
Billing fraud involving government healthcare programs is a federal crime and can carry extremely harsh penalties, even for first-time offenders. Convictions may include:
- Up to 10 years in federal prison per count (under 18 U.S.C. § 1347)
- Fines of up to $250,000 per count
- Exclusion from Medicare and Medicaid programs
- Loss of medical license or DEA registration
- Civil liability under the False Claims Act (FCA)
- Treble damages and statutory penalties in civil fraud cases
The government may also seek asset forfeiture or clawbacks of past reimbursements. Prosecutors will often add conspiracy, wire fraud, or mail fraud charges to increase sentencing exposure.
Defending Against Upcoding and Unbundling Charges
At Sosinsky Law, we take a proactive and aggressive approach to defending healthcare providers accused of upcoding or unbundling fraud. Our defense strategy focuses on negating criminal intent, challenging audit methodology, and attacking the credibility of government witnesses or data. Our defense efforts often include:
- Analyzing claim data to identify patterns that support good-faith billing
- Challenging vague or subjective coding standards
- Presenting expert testimony from medical billing consultants or coders
- Arguing that discrepancies are the result of clerical errors or misunderstanding, not fraud
- Demonstrating that claims were consistent with the medical necessity of services rendered
- Negotiating with federal prosecutors to avoid criminal charges or reduce exposure
We also explore all available civil settlement or administrative resolution options, especially in cases where there is no clear evidence of willful intent.
Early Legal Intervention Can Change the Outcome
Many healthcare fraud investigations begin quietly—with an audit, data request, or subpoena. These early stages are critical opportunities to shape the outcome of the case. The decisions you make in the first 30 days of an investigation may determine whether you’re facing civil fines, exclusion, or prison.
By retaining Sosinsky Law early, you give yourself the advantage of:
- Controlling the flow of information
- Avoiding self-incrimination during interviews or audits
- Preserving key documentation
- Presenting mitigating facts and legal arguments to investigators
- Negotiating a non-prosecution agreement or civil resolution
The sooner we are involved, the more we can do to protect your practice, license, and freedom.
Frequently Asked Questions
Can I go to prison for upcoding or unbundling?
Yes. If the government believes you intentionally submitted false claims, you could face criminal charges punishable by years in federal prison. Early legal representation is essential.
What’s the difference between an audit and a criminal investigation?
An audit is typically administrative and focuses on overpayments. A criminal investigation involves federal agents, subpoenas, and potential prosecution. Both can overlap—don’t assume an audit is low risk.
How does the government prove intent in billing fraud cases?
They use patterns, emails, witness testimony, internal policies, and statistical comparisons. Your defense lawyer will challenge the reliability and interpretation of that evidence.
What should I do if I receive a subpoena or target letter?
Contact an experienced healthcare fraud attorney immediately. Do not speak to investigators or produce documents without legal guidance. Early response can protect your rights and reduce your exposure.
Contact Our Upcoding and Unbundling Fraud Defense Lawyer Now
If you’re under investigation for upcoding, unbundling, or healthcare billing fraud, do not wait for formal charges to be filed. These cases can result in catastrophic consequences for your medical license, finances, and freedom, but with the right legal strategy, you may be able to resolve the matter before it escalates.
At Sosinsky Law, we help healthcare professionals in New York City protect what they’ve worked so hard to build. Our firm is ready to review your case, explain your options, and begin building a powerful defense.
Call Sosinsky Law today for a confidential consultation with a trusted healthcare fraud defense lawyer in New York City.