Medicaid False Claims Legal Exposure Analyzer

Claim Parameters

Case Scenario Presets

Total Disputed Claims 1,420 claims

Total Medicaid Reimbursement ($)

Per-Claim Penalty Tier (DOJ Adjusted)

Actual Damages Multiplier 3.0x (Treble)

Qui Tam Relator Share 20% (Intervened range 15-25%)

Scienter Threshold (U.S. ex rel. SuperValu)

5th Circuit Procedural Posture & Defenses

Stage 1

Motion to Dismiss

Stage 2

Factual Discovery

Stage 3

Summary Jdgmt

Stage 4

Bench/Jury Trial

Factual Discovery Phase (Rule 26)

Denial of motion to dismiss forces comprehensive discovery into internal billing records, state regulatory exclusion mailings, and subjective understanding of program termination dates.

Evidentiary Sufficiency Checklist (FCA / TMFPA) 4/4 Met

Materiality Standard (Universal Health Servs. v. Escobar)

Medicaid termination notice was condition of payment, not merely condition of participation.

Scienter Requirement (SuperValu Subjective Belief)

Defendant had notice or reckless disregard regarding Medicaid provider exclusion validity.

Legal / Factual Falsity Established

Claims submitted during active notice window without stay or preliminary injunction in effect.

Qui Tam Original Source / Relator Standing

Relator possesses direct and independent knowledge overcoming public disclosure bar.

Liability Distribution (Treble Damages vs Mandatory Penalties)

Computed Legal Liability

Total Potential Exposure (Max)

$43,615,560

Min: $24,431,360 — Max: $43,615,560

Base Single Reimbursement $1,750,000

Trebled Damages (3x) $5,250,000

Statutory Penalties (Min) $19,181,360

Statutory Penalties (Max) $38,365,560

Relator Bounty Share (20%) $4.89M – $8.72M

State/Federal Recovery Net $19.55M – $34.89M

Live Compliance Audit Summary

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