Glossary

The average price paid to a manufacturer by wholesalers for drugs distributed to retail pharmacies. AMP is used in calculating Medicaid rebates to the states. It is not publicly available.

Assistant U.S. Attorney (AUSA)

An Assistant U.S. Attorney prosecutes criminal and civil matters involving violations of federal law, including qui tam whistleblower cases under the federal False Claims Act.

Average Wholesale Price (AWP)

A national average of list prices charged by wholesalers to pharmacies. AWP is sometimes referred to as a "sticker price" because it is not the actual price that larger purchasers normally pay.

Corporate Integrity Agreement (CIA)

The Department of Health & Human Services' Office of Inspector General (OIG) often negotiates compliance obligations with health care providers and other entities as part of the settlement of Federal health care program investigations arising under a variety of civil false claims statutes. A provider or entity, such as a pharmacy, consents to these obligations as part of the civil settlement and in exchange for the OIG's agreement not to seek an exclusion of that health care provider or entity from participation in Medicare, Medicaid and other federal health care programs. These compliance measures seek to ensure the integrity of federal health care program claims submitted by the provider.

Centers for Medicare & Medicaid Services (CMS)

The federal agency that runs the Medicare program. In addition, CMS works with the States to run the Medicaid program. CMS works to make sure that the beneficiaries in these programs are able to get high quality healthcare.

Department of Justice (DOJ)

The Washington, D.C.-based federal agency that prosecutes criminal matters and represents the federal government as plaintiff or defendant in civil matters.

Deficit Reduction Act of 2005 (DRA)

In February 2006, Congress enacted Section 6031 of the Deficit Reduction Act of 2005, S. 1932, which added section 1909(b) to the Social Security Act. The provision was passed to encourage states without False Claims Acts to pass their own versions of the federal law since the law included the provision that States with qualifying FCAs receive an additional 10 percent of Medicaid fraud awards.

False Claims Act (FCA)

Originally called the "Lincoln Law," the federal False Claims Act, originated during the Civil War, was designed to combat Union Army supplier profiteering. For most of its history, the FCA was used to fight defense industry fraud. In recent years, the law has been used in whistleblower lawsuits in the healthcare arena to recover for false or fraudulent Medicare or Medicaid claims. The qui tam provision allows an individual to file an FCA case under seal and gives the government the right to join the action. If the government declines to intervene, the qui tam whistleblower may proceed on his or her own.

Federal Upper Limit (FUL)

Federal price ceilings are known as the "Federal upper limit." According to the United States Department of Health and Human Services, the "Federal upper limit program was put in place to ensure that the Federal Government acts as a prudent payer by taking advantage of current market prices" for generic drugs. Under the program, the federal government mandates that states pay no more than 150 percent of the published price of any drug that has three or more competing suppliers.

Formulary

A list of drugs covered by a plan.

Health Care Financing Administration (HFCA)

The Health Care Financing Administration (HCFA) was the predecessor of today's Center for Medicare and Medicaid Services (see CMS above).

Maximum Allowable Costs (MAC)

These are state limitations on the price that Medicaid will reimburse a pharmacy for a particular drug. Also known as "State Upper Limits."

Medicaid Fraud Control Unit (MFCU)

The state-level agencies that investigate Medicaid fraud and part of the states' attorneys general offices. MFCUs were created by Congress in 1977 as federal and state-funded law enforcement entities to investigate and prosecute health care provider fraud and violations of state law pertaining to Medicaid fraud. MFCUs also are required to review complaints of resident abuse or neglect in nursing homes and other healthcare facilities.

National Association of Medicaid Fraud Control Units (NAMFCU)

The National Association of Medicaid Fraud Control Units (NAMFCU) was founded in 1978. Today all 50 federally-certified MFCUs are members of the association. Each unit is represented by its Director. There are six NAMFCU regions in the U.S.

Omnibus Budget Reconciliation Act of 1990 (OBRA 90)

Federal legislation that, for the first time, set rebate provisions for prescribed drugs under Medicaid per legislation known as the Medicaid Rebate Act.

Office of the Inspector General (OIG)

The Office of Inspector General of the U.S. Department of Health & Human Services ("HHS") protects the integrity of HHS programs and the health and welfare of those programs' beneficiaries. The OIG must report to the HHS Secretary and Congress any program and management problems and recommendations to correct them. The OIG's duties are carried out through a nationwide network of audits, investigations, inspections and other mission-related functions performed by its components.

United States Attorney's Office (USAO)

There are 93 federal districts in the U.S. In each district, the chief law enforcement officer is the U.S. Attorney whose responsibilities include prosecuting federal civil and criminal cases on behalf of the United States. The USAO also defends the U.S. in cases filed in their districts.