Anti-Kickback Statute: Medicare and Medicaid Patient Protection Act of 1987, 42 U.S.C. §1320a-7b.
Bid Rigging: A type of price fixing that is a False Claims Act violation. In bid rigging, a group of companies collude to keep the price higher than fair market value when they bid for a government contract.
Burden of Proof: The burden of proof is a term for what a Plaintiff or Defendant must prove in order to establish a given claim. In most False Claims Act cases, the burden of proof is on the Plaintiff to prove that the company defrauded the government.
Complaint: The Complaint is the first document filed in a case by the Plaintiff. In False Claims Act cases, the Complaint is filed in camera and under seal. In addition the Complaint, the Plaintiff serves other supporting documents on the federal government so that it can investigate the case. The Government assesses whether or not it will pursue the case based on the contents of this file, so including the proper information is vital.
Contingency: Schiller & Schiller is paid on contingency bases in False Claims Act cases. This means that the law firm receives a percentage of the recovery rather than billing the client by the hour.
Cost Report Fraud: Occurs when a contractor overestimates the cost of a particular government contract in order to collect excess money from the government.
Cost-Plus Contract: Defense Contractor is paid for its costs plus profit.
Cross-Charging: When a Defense Contractor charges time spent working on a fixed-price contract to a cost-plus contract.
Damages: The money that a Defendant has to pay when they lose a case. Private citizens who file False Claims Act cases under the Qui Tam provision are entitled to a share of any damages the Defendant pays. This may include compensatory damages meant to pay the Plaintiff for actual injury suffered. This may also include punitive damages, which are meant to punish the Defendant for their acts.
Defendants: Defendants are the people or companies accused of defrauding the government in a particular case, in other words, they are the people or companies that False Claims Act suits are filed against
Discovery: The process in which Plaintiffs and Defendants in a case request the information relevant to the claim(s) from one another. In a False Claims Act suit this process is unique and has another dimension. The Complaint in a FCA suit is initially filed under seal and must contain supporting documents. Government representatives use the contents of this sealed file to determine whether or not they will pursue the case.
Dispositive Motions: A motion in which one party (usually the defendant) seeks to dismiss (“dispose of”) part or all of the other party’s claims. The motion common dispositive motions are motions to dismiss and motion for summary judgment. Motions to dismiss are usually made at the beginning of the case, just after the case is filed. Motions for summary judgment are usually made after discovery is complete.
Fixed-Price Contract: The contractor agrees to be paid the flat amount of money, regardless of how long a project takes.
Fraudulent Cost Reports: Providers may attempt to defraud Medicaid or Medicare through fraudulent billing. For example, Providers may knowingly inflate costs, mischaracterize costs or misrepresent the percentage of costs that they dedicated to Medicare patients.
Hospice Fraud: Hospice fraud is an example of unbundling. Fraud occurs when the hospice is billing for services at the correct level of care, and whether arrangements with nursing facilities to provide services involves kickbacks.
In Camera: In private with the judge, as opposed to in open court. False Claims Act cases are filed under seal and in camera. This is done to keep the case private while the federal government investigates the case.
Internal Government Investigations: Conducted by the government after the sealed Complaint is filed in a False Claims Act case to assess whether the government will pursue the case. A notification of their decision if sent to the private individual who filed the claim on the government’s behalf. If the government pursues the case, the private citizen will be entitled to a portion of the damages.
Kickback: Kickbacks involve improper arrangements whereby providers give a benefit to other providers for proscribing their products or using their products or services. These schemes can come in many forms.
Lack of Medical Necessity: Occurs when providers bill Medicare or Medicaid for patient procedures that are not medically necessary.
Lincoln Law: Casual term for the False Claims Act.
Medicaid Fraud: Defrauding medicaid, a government program that provides for the healthcare needs of low-income individuals and families. There are a variety of types of Medicaid Fraud that can be prosecuted under the False Claims Act.
Medicare Fraud: Defrauding Medicare, a national social insurance program. There are a variety of types of Medicare Fraud that can be prosecuted under the False Claims Act.
Mischarging: When a contractor increases its bill to the government by charging for costs (such as parts and labor) that are more than the costs that the contractor actually paid.
Off-Label Marketing: Drugs must be approved by the FDA for specific uses before they can be sold in interstate commerce. Once approved for any use, they may be prescribed by physicians for unapproved, or “off-label,” uses as well. However, “misbranded” drugs, meaning drugs lacking directions for the drug’s use which would enable a layperson to use the drug safely and for its intended uses, are prohibited in interstate commerce.
Penalties: Financial penalties to the person or organization includes recovery of three times the amount of the false claim(s), plus an additional penalty of $5,500.00 to $11,000.00 per claim.
Pharmaceutical Fraud: Fraud that has to do with the approval, manufacture, marketing, distribution or pricing of pharmaceutical products.
Product and Service Substitution: When a company or contractor provides products or services other than those specified in a Government contract without the Government’s approval.
Product Substitution: Governments often specify the particular products to be used. Fraud may occur if a Defense Contractor substitutes a material, often to lower costs, without the Government’s approval.
Punitive Damages: Punitive damages are meant to punish the Defendant for wrongful conduct. Punitive damages may be awarded in a False Claims Act case.
Qui tam: A provision in the False Claims Act that allows private citizens to file False Claims Act claims on the behalf of the Federal Government. Filing these claims is informally known as “whistleblowing.” The official term for individuals filing these private suits is “relator.”
Relator: A private individual who files a claim under the False Claims Act’s Qui Tam provision on the behalf of the Government. The relator does not need to have been personally affected by the fraudulent conduct.
Research Grant: Made up of Government funds given to people or institutions for a particular purpose [i.e. cancer research, etc]. The grant documents reflect the specific purposes for which governments funds may be used. A False Claims Act case may arise when these funds are not used for the purposes specified.
Service of Process: Process is served when the Complaint is “served” on the Defendant, In a False Claims Act case, this happens only after the government has given their approval.
Settlement of Actions: Actions settle when the Defendant chooses to compromise with the Plaintiff and pay a given amount in damages to resolve the case. Settlements usually take place after Discovery, but before trial.
State False Claims Act: North Carolina has a State False Claims Act that imposes liability on people or companies who knowingly defraud the state government. Potential violations include: presenting false or fraudulent claims for payment to the state and deceptively avoiding binding obligations to pay the state among others. A private individual may file suit on behalf of the state government and collect a portion of the damages.
Statute of Limitations: Statutes of Limitations provide deadlines after which a claim will be lost if not filed.
Stay of Proceedings: Proceedings in a False Claims act may be stayed pending a government investigation of the allegations contained in the Complaint.
Truth In Negotiations Act [TINA]: TINA requires that a contractor truthfully disclose information about its costs to the government so that the government can make an informed decision about the price of a contract.
Unbundling/ Fragmentation: Medicare and Medicaid often have special rates for groups of procedures that are normally done together. Providers may defraud these government programs by billing each procedure separately in order to receive a higher reimbursement.
Upcoding: Medicare and Medicaid billing designates a number to represent each service. Reimbursements to health care providers are based on the codes on the bills the providers prepare and submit. Upcoding occurs when a provider defrauds the government by submitting the code for a more complex or expensive procedure than the one actually performed in order to receive a higher reimbursement.
Whistleblower reward: The award given to whistleblowers under the False Claims Act. Typically, the reward is between 15 to 30 percent of the government’s recovery.
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