U.S. Health Care System Notes PDF

**[DOMAIN I]** **[THE BASIC STRUCTURE OF THE U.S. HEALTH CARE SYSTEM]** **Types of Service Codes** \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ **Types of I...

**[DOMAIN I]** **[THE BASIC STRUCTURE OF THE U.S. HEALTH CARE SYSTEM]** **Types of Service Codes** \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ **Types of Insurance/Products** **Limited/Supplemental Plans** - Insureds can either be reimbursed for their prescription drug expenses using standard claim forms - prescription drug card can be issued and allows prescriptions to be paid for by paying only the deductible with each prescription purchase - **Medical Benefits** -- provided without limit, employee is entitled to receive all necessary medical and surgical treatment for his or her condition. - **Income benefits** -- paid to employees who suffer work‐related disabilities - **Death benefits** -- provide two types of payments. Up to a certain dollar amount is provided as a burial allowance, and weekly income payments are paid to a surviving spouse and/or children. - **Rehabilitation benefits** -- are recognized as a tool for reducing workers' compensation costs and returning disabled employees to work. Rehabilitation may include therapy, vocational training, devices such as wheelchairs, and cost of travel, lodging and living expenses while being rehabilitated. **GAP** -- covers gaps in insurance coverage \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ **Federal & State Programs** **Medicare Part A** (Hospital Insurance Coverage) **Medicare Part B** (Medical Insurance Coverage) **Medicare Advantage Plans** (Part C or MA Plans) **Medicare Part D** (Prescription Drug Coverage) **Tricare** - health care program managed by Defense Health Agency for active duty, guard, reserves, and retired members of the uniformed services and their families. **FEHBP** -- Federal Employees Health Benefits Program; health benefits to full‐time federal civilian employees, their families, and qualified retirees **Medicaid** -- established in 1965 to provide health care coverage for certain low‐income families, as well as certain low‐income aged, blind, and disabled individuals **Marketplace** -- aka the exchange, a place (both online and in-person) where consumers in the United States can purchase private individual/family health insurance plans and receive income-based subsidies \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ **Basic Legal Aspects of the U.S. Health Care System-Anti-Fraud Focus** **Regulation of Healthcare** **Plan Funding and Applicable Regulations** - health insurance through commercial insurers usually negotiate on behalf of their employees for specific benefits at a specified monthly premium per person or family - Fully‐Insured Accident & Health policies cover groups of an employees while their employer pays the premium to the insurance company - self‐insured plans can contract with commercial insurance companies to provide Administrative Services Only (ASO) for claims processing or for access to a provider network. Alternatively, they can contract with a Third-Party Administrator (TPA) for the same services. The TPA is not an insurance company **Employee Retirement Income Security Act of 1974 ("ERISA")** ERISA broadly preempts state law to establish and preserve uniform and exclusive federal regulation of covered employee benefit plans. ERISA Regulates any plan, fund, or program maintained for the purpose of providing retirement, medical or health benefits for employees or their beneficiaries. ERISA is the primary source of regulation for self‐funded plans, but also applies to insured health benefit plans. **The Affordable Care Act (ACA)** The landscape of health insurance regulation begins to change with the enactment of the Patient Protection and Affordable Care Act later dubbed the ACA. The ACA creates an entirely new overlay of federal regulation of health insurance. While states continue to have primary responsibility for regulating insurance, the ACA applies several additional federal regulatory parameters. \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ **Federal Anti-Fraud Statutes** **The Health Insurance Portability and Accountability Act of 1996 (HIPAA)** HIPAA amended ERISA, the Public Health Service Act, and the Internal Revenue Code. (42 U.S.C. sec. 1320a‐7c). Two key areas of HIPAA are - Title I: Health Care Access, Portability, and Renewability - Title II: Preventing Health Care Fraud and Abuse; Administrative Simplification; Medical Liability Reform. - The HIPAA [Privacy Rule] established rules for the use and disclosure of Protected Health Information ("PHI"). - The HIPAA [Security Rule] complements the HIPAA Privacy Rule. The Privacy Rule pertains to all PHI, paper and electronic, whereas the Security Rule applies specifically to electronic PHI. The security rule creates three areas of security safeguards and compliance: administrative, physical, and technical. - The [Unique Identifiers Rule] creates and mandates use of a single National Provider Identifier ("NPI"). Compliance was required in May 2007. **HITECH ACT** The Health Information Technology for Economic and Clinical Health Act ("HITECH") was enacted in 2009 as part of the American Recovery and Reinvestment Act (referred to as the Stimulus) and creates new tools for aggressive enforcement of the HIPAA rules. - increases penalties for violations of the HIPAA Privacy Rules from the current high of \$25,000 to as much as \$1.5 million - requires most security breaches be reported not only to the patient but also to the government, and in some situations, the media **Anti**‐**Kickback Statute (AKS) (42 USC sec 1320a**‐**7b(b)** Anyone who knowingly and willfully solicits, receives, offers or pays any remuneration (including any kickback, bribe or rebate) directly or indirectly, overtly or covertly, in cash or in kind in return for referrals or for the purchase, lease, or order of any good, facility or service for which any federal health care program may pay in part or whole \--commits a felony. - punishable by fines up to \$25,000, imprisonment up to 5 years, or both - violators are also subject to exclusion from federal health care programs and to civil monetary penalties up to \$50,000 for each violation and up to triple the amount of remuneration offered, paid, solicited, or received - The AKS applies only to federal health care programs - person need not have actual knowledge of \[the AKS\] or specific intent to commit a violation **STARK Anti**‐**Referral Statute (42 U.S.C. sec. 1395nn)** The STARK law prohibits physicians with direct or indirect financial interests in an entity from making referrals to that entity for "designated health services" ("DHS") payable by Medicare or Medicaid unless an exception applies. - applies without regard to the intent or knowledge of the physician making the referral or the entity furnishing the DHS - Unlike the AKS, the Stark law is a *civil* statute - Penalties include non‐payment of services, CMPs, refunds of amounts billed, exclusion from Medicare and Medicaid, and a penalty up to \$100,000 for a circumvention scheme **Civil False Claims Act (31 U.S.C. secs. 3729‐3733)** The Civil False Claims Act prohibits persons or entities from, among other actions, knowingly presenting or causing to be presented to the federal government a false or fraudulent claim for payment or approval, and from knowingly making, using, or causing to be made or used a false record or statement to get a false or fraudulent claim paid or approved by the federal government. - penalties for False Claims Act (FCA) violations to range from at least \$12,537 to \$25,076 for each separate violation of the law, plus triple the amount of damages to the federal government - The standard of proof is a preponderance of the evidence. - authorizes private qui tam ("whistleblower") actions - and can recover 15 to 25% of the government's recovery, if the government intervenes, or 25 to 30%, if the government does not intervene **False Claims Act (FCA) -- Return of Overpayments** Providers and insurers participating in federal health care programs have a legal obligation to report and return overpayments received from Medicare and Medicaid. This is consistent with the new False Claims Act amendments, where a failure to return an overpayment in light of a legal obligation constitutes a "false claim." An overpayment must be reported and returned by the later of: **Civil Monetary Penalties Statutes (42 U.S.C. sec. 1320a**‐**7a)** The Civil Monetary Penalties Statutes provide for civil monetary penalties (CMP) and exclusion from federal health care programs for a wide range of conduct that encompasses the concept of improperly filed claims. Examples of conduct subject to penalty include: - A false statement prohibition in "any application, agreement, bid, or contract to participate or enroll as a provider of services or supplier under a Federal health care program" (including Medicare Advantage organizations and Part D sponsors). **Health Care Fraud Statute (18 U.S.C. sec. 1347)** Title II of HIPAA created a federal offense of Health Care Fraud applicable to "health care benefit programs" which includes commercial health insurance plans. The Health Care Fraud Statute prohibits executing or attempting to execute a scheme or artifice to defraud or to fraudulently obtain money or property from any health benefit program. Penalty for health care fraud includes fines and imprisonment for not more than 10 years; if serious bodily injury occurs, then imprisonment for not more than 20 years; and if death occurs, imprisonment for life is available. **Health Care Benefit Program False Statements Statute (18 U.S.C. sec. 1035)** The Health Care Benefit Program False Statements Statute prohibits falsifying or concealing a material fact or making false statements in connection with the delivery of health care benefits, items or services. Penalty includes fines and up to 5 years in prison. **Mail Fraud (Frauds and Swindles) (18 U.S.C. sec. 1341)** The Mail Fraud Statute makes it a federal crime to engage in any scheme to defraud any person that involves use of the U.S. mail or an interstate commercial carrier. This is the most commonly used statute in fraud cases (i.e., fraud cases that may or may not include health care fraud). Merely mailing (FedExing, etc.) a fraudulent health care claim or even mailing a premium payment connected to a fraudulent scheme constitutes a violation of this statute. Penalty includes fines and up to 20 years in prison. **Compliance Plans** HHS‐OIG published compliance program guidance for various segments of the U.S. health care system. Under the ACA, compliance plans are required for all Medicare participating providers and require certain elements that flow from the U.S. Sentencing Guidelines: **Affordable Care Act (ACA)** The Final Rule was published February 2, 2011. Key provisions that have resulted in promulgation of rules: - Section 6401 Provider screening and other enrollment requirements under Medicare, Medicaid, and CHIP. Also addresses temporary moratorium on the enrollment of new providers and mandates provider/supplier compliance programs. - Section 6402(h) Suspension of Medicare and Medicaid Payments Pending Investigation of Credible Allegations of Fraud. - Federal Register (76 FR 5862) Title: "Medicare, Medicaid, and Children's Health Insurance Programs; Additional Screening Requirements, Application Fees, Temporary Enrollment Moratoria, Payment Suspensions and Compliance Plans for Providers and Suppliers." Federal Register : Medicare, Medicaid, and Children\'s Health Insurance Programs; Additional Screening Requirements, Application Fees, Temporary Enrollment Moratoria, Payment Suspensions and Compliance Plans for Providers and Suppliers \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ **Key Federal, State, and Independent Agencies** **Federal Agencies** **State Agencies** **[Medicaid Program Integrity Units ]** \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ **Federal Antitrust Laws and Anti‐Fraud Information Sharing** **Federal Antitrust Laws** The purpose of the antitrust laws is to protect consumers by preserving free competition in the market for goods and services. One of the foundations for a free market economy. States also have antitrust laws which mirror the federal laws. Under antitrust law, some activities are per se illegal, while others are analyzed for illegality under a rule of reason test. Primary federal laws are Sections 1 and 2 of the Sherman Act and Section 5 of the Federal Trade Commission ("FTC") Act. These laws have dual enforcement by both the Antitrust Division of DOJ and the FTC. In the health insurance context, the following are examples of per se illegal activity: - Collective decisions not to do business with certain providers (group boycott). - Collective decisions not to cover or pay for certain items or services. - Collective decisions on premium rates or market allocations. - Discussions among competitors about such topics. **Anti-Fraud Information Sharing** The exchanges of information among competitors directed at fighting fraud are generally recognized as lawful, at least in circumstances where participants in the information exchange remain free to make their own independent decisions regarding whether or not to pursue an investigation or take other action based on the information. Law enforcement guidelines arising from HIPAA encourage the sharing of information regarding health care fraud among private insurers and federal and state law enforcement agencies. **Immunity, Privilege, and Defamation** **[Immunity ]** \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ **[DOMAIN II]** **[THE BUSINESS AND OPERATIONS OF THE HEALTH CARE INSURANCE SYSTEM]** **The Provider Life Cycle, Unique Business Models and Payment Arrangements** Provider Credentialing and Contracting [Contracting] **Departments Involved in Supporting Contracted Providers** Health Plans maintain several specialty groups who support providers (both Participating and Non-Participating) including the following: **Maintaining Relationships with Contracted Providers** **Claims are submitted in various methods** [Paper Claims ] **Policies and processes that may affect claim processing** \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ **Data Transmission, Technology Footprint, and Implications to Investigations** **Various Documents/Forms that include Information for an Investigation** **How to Follow the Trail** With the advent of technology, many previously paper-based forms are electronic. However, there is still a wide array of information in paper format that needs to be obtained and reviewed in an investigation (i.e., medical records). When conducting a thorough investigation, all relevant electronic and paper information should be considered and analyzed. Understand what types of information are available to you, as mentioned throughout this guide, and focus on key aspects that will paint a picture and help make a determination based on suspicion of FWA. [Investigative Technologies and Services ] [External Organizations that Provide Information for Investigations ] [Resources That Provide Education and Information for Investigations ] [Law Enforcement Information] [\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_] **Fraud, Waste and Abuse (FWA) Information Sharing** **Federal HCFACP and Information Sharing** **Healthcare Fraud Prevention Partnership (HFPP)** **NHCAA Information-Sharing** **Permissibility** **When to Share Information** \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ **Acronym Glossary** **AAAHC - Accreditation Association for Ambulatory Health Care** An organization which accredits ambulatory health care organizations and advocates for provision of high-quality health care through the development and adoption of nationally recognized standards. **ACA - Affordable Care Act** The comprehensive health care reform law enacted in March 2010 (sometimes known as ACA, PPACA, or "Obamacare"). The law was enacted to make affordable health insurance available to more people, expand the Medicaid program to cover all adults with income below 138% of the FPL. Support innovative medical care delivery methods designed to lower the costs of health care generally. **AHIP - America's Health Insurance Plans** The national association whose members provide health and supplemental benefits through employer-sponsored coverage, the individual insurance market, and public programs such as Medicare and Medicaid. **AKS - Anti-Kickback Statute** Federal criminal law that makes it a crime to knowingly and willfully offer, pay, solicit, or receive any remuneration directly or indirectly to induce or reward patient referrals or the generation of business involving any item or service reimbursable by a federal health care program. **ASO - Administrative Services Only** A plan provided to administer employee health claims. **BCBSA - BlueCross BlueShield Association** A national federation of 38 independent, community based and locally operated Blue Cross Blue Shield companies. **CHAP - Community Health Accreditation Partner** An independent, nonprofit accrediting body for home and community-based health care organizations. **CMP - Civil Monetary Penalty** A fine imposed on a person or entity for violation of a law or regulation. **CMS - Centers for Medicare & Medicaid Services** Part of the Department of Health and Human Services that oversees the Medicare and Medicaid programs. **COB - Coordination of Benefits** The transmission of benefit information from any entity to a health plan for the purpose of determining the relative payment responsibilities of a health plan for health care claims or payment information on a person with coverage under more than one health plan. **COBRA - Consolidated Omnibus Budget Reconciliation Act of 1985** A law that allows workers under certain circumstanced and for limited periods of time to continue with health benefits provided by their Group Health plan. **CPC - Certified Professional Coder** A credential given to a person who passed a medical coding certification examination given by the **CPI - Center for Program Integrity** Part of CMS, a body that aids in detecting and preventing fraud, waste, and abuse in the CMS programs. **DHS - Designated Health Services** Included in the Stark Law, a list of health services that appeared to be overutilized by referring physicians. The law prohibits a physician from making referrals for certain designated health services payable by Medicare to an entity with which he/she (or an immediate family member) has a financial relationship unless an exception applies. **DOJ - Department of Justice** A federal executive department of the United States government that enforces the law and defend the interests of the United States according to the law. **DOL - Department of Labor** A federal executive department of the United States government that oversees federal programs for ensuring a strong American workforce. **EBSA - Employee Benefits Security Administration** An agency within the Department of Labor that educates workers and regulates and enforces retirement, health, and other workplace related benefits. **EPO - Exclusive Provider Organization** A managed care plan where services are covered only if you go to doctors, specialists, or hospitals in the plan's network. **ERISA - Employee Retirement Income Security Act** A federal law that sets minimum standards for most voluntarily established health plans in private industry to provide protection for individuals in these plans. **FTC - Federal Trade Commission** A federal agency that works to prevent fraudulent, deceptive, and unfair business practices. **HCFAC - Health Care Fraud and Abuse Control Program** Program designed to coordinate federal, state, and local law enforcement activities with respect to health care fraud and abuse. **HFPP - Health care Fraud Prevention Partnership** A voluntary public-private partnership that helps detect and prevent health care fraud through data and information sharing. Partners include federal government, state agencies, law enforcement, private health insurance plans, employer organizations, and health care anti-fraud associations. **HHS -Department of Health and Human Services** A federal executive department of the United States government that administers Medicare and Medicaid and oversees the National Institutes of Health, the Food and Drug Administration, and Centers for Disease Control. **HIPAA - Health Insurance Portability and Accountability Act of 1996** A federal law that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient's consent or knowledge. **HMO - Health Maintenance Organization** A type of health insurance plan that usually limits coverage to care from doctors who work for contract with the HMO. It generally won't cover out-of-network care except in an emergency. An HMO may require you to live or work in its service area to be eligible for coverage. HMOs often provide integrated care and focus on prevention and wellness. **LEIE - List of Excluded Individuals and Entities** Provides information to the health care industry, patients and the public regarding individuals and entities currently excluded from participation in Medicare, Medicaid and all other federal health care programs. Individuals and entities who have been reinstated are removed from the LEIE. **MFCU - Medicaid Control Fraud Unit** Investigate and prosecute Medicaid provider fraud as well as abuse or neglect of residents in health care facilities and board and care facilities and of Medicaid beneficiaries in noninstitutional or other settings. **NAIC - National Association of Insurance Commissioners** A U. S. standard-setting organization with chief regulators from the 50 states, the District of Columbia, and the five U.S. territories that coordinate regulation of multistate insurers. **NCQA - National Committee for Quality Assurance** A nonprofit organization that exits to improve the quality of health care through Health care **NHCAA - National Health Care Anti-Fraud Association** A national organization focused on the fight against health care fraud by increasing awareness and improving the detection, investigation, civil and criminal prosecution, and prevention of health care fraud and abuse. **NPDB - National Practitioner Data Bank** A web-based repository of reports containing information on medical malpractice payments and certain adverse actions related to health care practitioners, providers, and suppliers. Established in 1986, it is a workforce tool that prevents practitioners from moving state to state without disclosure or discovery of previous damaging performance. **OIG - Office of the Inspector General** An independent, objective, oversight agency with dual reporting responsibility to the Secretary of Health and Human Services and to Congress that works with others to achieve systemic improvements, improved compliance, successful enforcement actions, and recovery of misspent funds. **OON - Out of Network** Providers or entities that do not participate in a health plans provider network. **PCP - Primary Care Provider** The physician or health care provider that a person usually goes to first (continually) for a majority of health care issues and to coordinate a person's health care. **POS - Point of Service** A type of plan in which you pay less if you use doctors, hospitals, and other health care providers that belong to the plan's network. They also require you to get a referral from your primary care doctor in order to see a specialist. **PPO - Preferred Provider Organization** A type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. You pay less if you use providers that belong to the plan's network. You can use doctors, hospitals, and providers outside of the network for an additional cost. **SIU - Special Investigations Unit** A specialized unit in a compliance department that compiles data to detect, investigate, and purse allegations of fraud, waste, and abuse. **TPA - Third Party Administrator** A business that specializes in administrative operations for other companies. **URAC - Utilization Review Accreditation Commission** An independent, nonprofit health care accreditation organization that uses evidence-based measures that are developed in collaboration with a wide array of stakeholders, including health plans, providers, and associations.