Compliance and fraud, waste and abuse
An overview of GEHA's Compliance Program
GEHA expects that all of its employees and business partners (including contractors, vendors and providers) will conduct business on behalf of GEHA and its subsidiaries in an ethical manner, with the highest level of integrity, and in compliance with all laws, regulations, and contract/legal requirements.
GEHA’s Compliance Program is designed to detect and prevent illegal or unethical conduct, promote integrity in the workplace, and align the actions of all GEHA employees and business partners with GEHA’s Vision, Corporate Values and Compliance Commitment.
- Our Vision: We inspire positive outcomes by delivering integrated health and well-being solutions at the best value.
- Our Corporate Values: Care for Our Members and Each Other; Work as One Team; Own It and Achieve Excellence; Commitment to Growth and Improvement; and Embrace Diversity and Inclusion.
- Our Compliance Commitment: Promote an organizational culture that encourages ethical conduct and a commitment to compliance with the law.
The Corporate Compliance Program is based on seven principles intended to ensure the effectiveness of the program:
- Implementation of written policies and procedures
- Providing compliance leadership and culture
- Providing effective compliance education and training programs
- Ensuring effective lines of communication for compliance efforts
- Monitoring and auditing compliance
- Enforcing the corporate compliance program
- Responding promptly to noncompliance and taking remedial action
Code of Ethical Business Conduct
GEHA requires all of its business partners to review, and be familiar with, the GEHA Code Of Ethical Business Conduct.
Obligation to report compliance/ethics and fraud, waste and abuse concerns
GEHA takes great pride in its reputation for ethical conduct and recognizes that it only takes one misguided or inappropriate action to put that valuable reputation at risk. GEHA, accordingly as an essential part of its Compliance Program, requires that all of its employees and business partners (including contractors, vendors, and providers) report any potential unethical, illegal, improper, or wrongful conduct or activity to GEHA. This obligation includes assisting GEHA to fight against medical and dental health care fraud, waste and abuse.
What is health care fraud, waste and abuse?
Fraud is generally defined as knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any health care benefit program or to obtain (by means of false or fraudulent pretenses representations, or promises) any of the money or property owned by, or under the custody or control of, any health care benefit program. (18 U.S.C. § 1347)
Waste is over-utilization of services or other practices that, directly or indirectly, result in unnecessary costs to the health care system, including the Medicare and Medicaid programs. It is not generally considered to be caused by criminally negligent actions, but by the misuse of resources.
Abuse is payment for items or services when there is no legal entitlement to that payment and the individual or entity has not knowingly and/or intentionally misrepresented facts to obtain payment.
Mechanisms for reporting
GEHA’s Ethics Hotline
Reports pertaining to any compliance/ethics issues or fraud, waste or abuse may be made by phone or through a dedicated website as follows:
GEHA works with local, state and federal agencies to report and investigate health care fraud. We encourage you to report incidents with our partners:
- Medicare/Medicaid health care fraud (Office of Inspector General, Department of Health and Human Services)
- Federal employee health care fraud (U.S. Office of Personnel Management)
- Commercial and public health care fraud (FBI)
- Using U.S. Postal Service for Post Office fraud (U.S. Postal Service Office of Inspector General)
- Identity fraud (Federal Trade Commission)
- National Health Care Anti-Fraud Association (Public/private partnership for health care fraud)