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Overview of PPO USA’s Compliance Program

PPO USA expects that all of its employees and business partners (including contractors, vendors, and providers) will conduct business on behalf of PPO USA in an ethical manner, with the highest level of integrity, and in compliance with all laws, regulations, and contract / legal requirements. PPO USA’s Compliance Program is designed to detect and prevent illegal or unethical conduct, promote integrity in the workplace, and align the actions of all PPO USA employees and business partners with PPO USA’s Mission, Vision, Corporate Values and Compliance Commitment.

  • Our Mission Statement: PPO USA provides niche products and leverages industry knowledge to help clients retain and grow business.
  • Our Vision Statement: PPO USA is a leader in leased dental network and care management solutions for health care payers and administrators, serving our chosen markets with tailored product offerings and superior client management, sustained by a nimble and efficient organization.
  • Our Corporate Values: Our clients are why we come to work every day. We strive to influence our industry - empowering our clients by providing valuable network solutions in an honest and ethical way.
  • 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:

  1. Implementation of written policies and procedures
  2. Providing compliance leadership and culture
  3. Providing effective compliance education and training programs
  4. Ensuring effective lines of communication for compliance efforts
  5. Monitoring and auditing compliance
  6. Enforcing the corporate compliance program
  7. Responding promptly to noncompliance and taking remedial action

Code of Ethical Business Conduct
PPO USA requires all of its business partners to review, and be familiar with, the PPO USA Code of Ethical Business Conduct.

Obligation to report compliance/ethics and fraud, waste and abuse concerns
PPO USA 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. PPO USA, 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 PPO USA. This obligation includes assisting PPO USA’s parent company, GEHA, as owner of the dental network that PPO USA leases, 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 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
PPO USA leverages GEHA’s Ethics Hotline as its mechanism for reporting compliance/ethics and fraud, waste and abuse matters. Reports pertaining to any compliance/ethics issues or fraud, waste or abuse may be made by phone or through a dedicated website as follows:

Phone: 844.510.0048
Available 24 hours a day, 365 days a year
Translators are available
Website: www.lighthouse-services.com/geha

Partners
PPO USA leases GEHA’s dental network and, therefore, GEHA is ultimately responsible for handling any reports made against those providers. GEHA works with local, state and federal agencies to report and investigate health care fraud. We encourage you to report incidents with GEHA's 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)