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GlobalHealth is committed to conducting business with honesty and integrity and in accordance with applicable Federal and State laws, regulations, sub-regulatory guidance and policies, including those related to participation in Medicare Advantage (MA) Programs. This commitment is evident through the demonstrated values and behavior of GlobalHealth employees and representatives. Therefore, GlobalHealth has established a Compliance Program that includes the following elements: (1) Compliance Officer; (2) Code of Conduct; (3) Policies and Procedures; (4) Education and Training; (5) Hotline for Reporting; (6) Risk Assessment; (7) Auditing and Monitoring; (8) Corrective Action and Enforcement; (9) Fraud, Waste and Abuse Program; and (10) FDR Oversight.
Code of Conduct
GlobalHealth has a written code of conduct that every GlobalHealth employee, agent and first-tier, downstream and related entity (FDR) is required to follow.
All employees, officers, directors, business associates and FDRs are expected to report known or suspected compliance violations. Members are encouraged to report any suspected compliance violation or concern and/or fraud, waste or abuse. GlobalHealth maintains a toll-free anonymous reporting hotline available to anyone to call and report a compliance violation or concern.
Reports may be submitted openly or anonymously. Should you have a concern about a possible compliance violation or potential fraud, waste or abuse, you may contact us through the following Confidential Reporting Lines: ACTright Hotline (available 24 hours/7 days) at 1-877-627-0004 or Web Reporting Line at globalhealth.ethicspoint.com
GlobalHealth is committed to detecting and preventing health care fraud. As part of our ongoing efforts in this area, we have developed a Compliance Program that includes methods to detect and deter fraud.
Fraud is 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, payment from a health care benefit program.
Waste is the overutilization of services, or other practices that result in unnecessary costs to federal health care programs (e.g., Medicare). Does not require knowledge or intent.
Abuse includes actions that may, directly or indirectly, result in unnecessary costs, improper payment, payment for services that fail to meet professionally recognized standards of care, or services that are not medically necessary. Abuse does not require knowledge or intent.
GlobalHealth uses external entities for certain administrative and health care services. These external entities are often referred to as First-Tier, Downstream and Related Entities (FDRs). GlobalHealth has adopted the Centers for Medicare & Medicaid Services (CMS) definition of First-Tier, Downstream and Related Entities.
First Tier Entity
A First Tier Entity is any party that enters into a written arrangement, acceptable to CMS, with an MA organization or Part D plan sponsor or applicant to provide administrative services or health care services to a Medicare-eligible individual under the MA program or Part D program. (See 42 CFR §§ 422.500 and 423.501.)
A Downstream Entity is any party that enters into a written arrangement, acceptable to CMS, with persons or entities involved with the MA benefit or Part D benefit, below the level of the arrangement between an MA organization or applicant or a Part D plan sponsor or applicant and a First Tier Entity. These written arrangements continue down to the level of the ultimate provider of both health and administrative services. (See 42 CFR §§ 422.500 and 423.501.)
A Related Entity means any entity that is related to an MA organization or Part D sponsor by common ownership or control and:
- Performs some of the MA organization or Part D plan sponsor’s management functions under contract or delegation
- Furnishes services to Medicare enrollees under an oral or written agreement
- Leases real property or sells materials to the MA organization or Part D plan sponsor at a cost of more than $2,500 during a contract period (See 42 CFR §§ 422.500 and 423.501.)