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False Claims Act

The methodology used in this research on the civil False Claims Act (FCA) is discussed in this chapter. Specifically, the research question and sub-questions are presented with each of their respective hypotheses. The necessary definitions are presented, and the research method and the data are described. The data analysis for each sub-question is then explained. Lastly, the chapter concludes by discussing the data reliability and limitations of the study. Which specific activities did the provider conduct?

Hypothesis: It was hypothesized that the types of accusations waged against providers would become more varied over time. In other words, a wider range of accusations would be filed against providers over time. As discussed in the preceding literature review and assessment of the policy issue, this prediction is based upon the repeated complaints from scholars and providers that the FCA is continuously being used more broadly against Medicare providers.

Which degree of knowledge, if any, did the Court find on the part of the provider in relation to the alleged activity? Hypothesis: It was hypothesized that many of the cases would focus on determining the level of a provider’s knowledge about the activity in question. This hypothesis was rooted in the legal literature which emphasized the room for broad interpretation of the post- 1986 FCA standard for “knowingly. ” It was anticipated that many of the cases that appeared in the courts would revolve around whether or not the provider should have known that a particular billing method was questionable.


Bases and opinions

In this study, a “case” is considered to be the compilation of written opinions about the same specific set of facts. An “opinion” is defined as the Court’s written statement on one aspect, or one proceeding, that is part of a larger case. For instance, a case could revolve around whether a provider was upcoding Medicare claims, and multiple opinions could be produced during the process of deciding that one case. For example, in a case against Kensington Hospital and some of its doctors, three opinions collectively represent the written case.

These three opinions include: 1) the defendants’ motion to dismiss the case (Kensington, 1991), 2) some defendants’ motion to compel the government to provide them with certain documents for review (Kensington, 1992), and 3) one defendant’s motion for summary judgment, seeking to dismiss the case filed against him (Kensington, 1993). While the initial data downloaded were opinions, the study uses two different units of analysis: 1) opinions, and 2) cases, or the compilation of all written opinions about the same specific set of facts.

The application of this two-tiered analysis will be discussed in more detail throughout this chapter. Because both levels of analysis are used, it is impossible to precisely and accurately discuss the methods used in this study without using both terms. In addition, the term “court data” will be used to refer collectively to both cases and opinions. Whenever any of these terms is used in this document, it has been chosen purposefully as the accurate term for discussing the specific information at hand. The definitions provided above serve as a clarification of what each term means for the purposes of this study.


Content analysis

In addition, this study broadly uses the term “plaintiff” to refer to any party who has filed a case against a defendant. This term is used to ease readability. The term “plaintiff” can defined as “the person who brings a lawsuit against another” and usually refers to a private, non-government entity (Jacobstein et al. , 1998). When a government attorney brings a case on behalf of the government they might more accurately be referred to as the “civil prosecutor” or simply “the government. ”

However, because this research discusses cases filed by both private individuals and the government, the term “plaintiff” is used throughout this study to broadly refer to the party or parties who filed a case against one or more defendants. For instance, the plaintiff categoriesthroughout Chapter 4 are labeled as “government-only” or “whistleblower-only. ” Instances where the government filed a case with a whistleblower are labeled as “joint plaintiff. ”

This research is based on the technique of content analysis. Content analysis has been described as the “study of recorded human communications”. It serves a means of converting written documents into quantitative data. Content analysis is “essentially a coding operation,” and this coding is used to convert raw data into a standard form. In this study, the content of FCA opinions were coded according to an established list of variables to allow for subsequent data analyses—including an analysis of data at the opinion level as well as at the case level.