[ A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z ] P . . . Participating Physician A primary care physician in practice in the payer's managed care service area who has entered into a contract. Participating Provider A health care provider who participates through a contractual arrangement with a health care service contractor, HMO, PPO, IPA or other managed care organization. Patient Liability The dollar amount which an insured is legally obligated to pay for services rendered by a provider. PCP Capitation A reimbursement system for healthcare providers of primary care services who receive a pre-payment every month. The payment amount is based on age, sex and plan of every member assigned to that physician for that month. Specialty capitation plans also exist but are little used. Peer Review A review by members of the profession "peers" regarding the quality of care provided a patient, including documentation of care (medical audit), diagnostic steps used, conclusions reached, therapy given, appropriateness of utilization (utilization review), and reasonableness of charges claims. The evaluation covers how well services are performed by all health personnel and how appropriate the services are to meet the patients' needs. Performance Standards Standards an individual provider is expected to meet, especially with respect to quality of care. The standards may define volume of care delivered per time period. Thus, performance standards for obstetrician/gynecologist may specify some or all of the following office hours and office visits per week or month, on-call days, deliveries per year, gynecological operations per year, etc. Per Member Per Month (PMPM) Specifically applies to a revenue or cost for each enrolled member each month. Per Thousand Members Per Year (PTMPY) A common way of reporting utilization. The most common example of hospital utilization, expressed as days PTMPY. Physician Attestation The requirement that the attending physician certify, in writing, the accuracy and completion of the clinical information used for DRG assignment. Physician Organization This term describes physician linkages and alliances that allow physicians to manage risk and capitation. Information systems, physician relationships, and financial integration allow these organizations to be more integrated than the traditional solo practice or IPA relationship between healthcare providers and/or managed care organizations that are working to develop a "seamless" continuum of healthcare services. Physician-Hospital Organization (PHO) A contracted arrangement among physicians and hospital(s) wherein a single entity, the PHO, agrees to provide services to insurers' subscribers. Plan Administration A term often used to describe the management unit with responsibility to run and control a managed care plan - includes accounting, billing, personnel, marketing, legal, purchasing, possibly underwriting, management information, facility maintenance, servicing of accounts. This group normally contracts for medical services and hospital care. Point-of-Service Plan (POS) Also known as an open-ended HMO, POS plans encourage, but do not require, members to choose a primary care physician. As in traditional HMOs, the primary care physician acts as a "gatekeeper" when making referrals; plan members may, however, opt to visit non-network providers at their discretion. Subscribers choosing not to use the primary care physician must pay higher deductibles and copays than those using network physicians. Practical Nurses Practical nurses, also known as vocational nurses, provide nursing care and treatment of patients under the supervision of a licensed physician or registered nurse. Licensure as a licensed practical nurse (L.P.N.) or in California and Texas as a licensed vocational nurse (L.V.N.), is required. Practice Parameters Strategies for patient management, developed to assist physicians in clinical decision making. Practice parameters may also be referred to as practice options, practice guidelines, practice policies, or practice standards. Preadmission Review The practice of reviewing claims for inpatient admission prior to the patient entering the hospital in order to assure that the admission is medically necessary. Preauthorization A method of monitoring and controlling utilization by evaluating the need for medical service prior to it being performed. Pre-Certification The process of notification and approval of elective inpatient admission and identified outpatient services before the service is rendered. Predetermination An administrative procedure whereby a health provider submits a treatment plan to a third party before treatment is initiated. The third party usually reviews the treatment plan, monitoring one or more of the following: patient's eligibility, covered service, amounts payable, application of appropriate deductibles, copayment factors and maximums. Under some programs, for instance, predetermination by the third party is required when covered charges are expected to exceed a certain amount. Similar processes: pre-authorization, pre-certification, pre-estimate of cost, pretreatment estimate, prior authorization. Pre-Existing Condition One of the following: A physical condition of an insured person which existed prior to the issuance of his policy or his enrollment in a Plan, and which may result in the limitation in the contract on coverage or benefits. A physical condition including an injury or disease that was contracted or occurred prior to enrollment in the HMO. Federally-qualified HMOs cannot limit coverage for pre-existing conditions. Preferred Provider Organization (PPO) One of the following: Some combination of hospitals and physicians that agrees to render particular services to a group of people, perhaps under contract with a private insurer. The services may be furnished at discounted rates and the insured population may incur out-of-pocket expenses for covered services received outside the PPO if the outside charge exceeds the PPO payment rate. A health care arrangement between purchasers of care (e.g., employers, insurance companies) and providers that provides benefits at a reasonable cost by providing members incentives (such as lower deductibles and copays) to use providers within the network. Members who prefer to use nonpreferred physicians may do so, but only at a higher cost. Preferred providers must agree to specified fee schedules in exchange for a preferred status and are required to comply with certain utilization review guidelines. Prepaid Group Practice Prepaid Group Practice Plans involve multi-specialty associations of physicians and other health professionals, who contract to provide a wide range of preventive, diagnostic and treatment services on a continuing basis for enrolled participants. Prepayment A method providing in advance for the cost of predetermined benefits for a population group, through regular periodic payments in the form of premiums, dues, or contributions, including those contributions which are made to a Health and Welfare Fund by employers on behalf of their employees. Primary Care Provider (PCP) A primary care provider such as a family practitioner, general internist, pediatrician and sometimes an ob/gyn. Generally, a PCP supervises, coordinates and provides medical care to members of a plan. The PCP may initiate all referrals for specialty care. Principal Diagnosis The medical condition that is ultimately determined to have caused a patient's admission to the hospital. The principal diagnosis is used to assign every patient to a diagnosis related group. This diagnosis may differ from the admitting and major diagnoses. Profile Aggregated data in formats that display patterns of health care services over a defined period of time. Profile Analysis Review and analysis of profiles to identify and assess patterns of health care services. Prospective Payment System (PPS) A payment method that establishes rates, prices or budgets before services are rendered and costs are incurred. Providers retain or absorb at least a portion of the difference between established revenues and actual costs. Primary Care One of the following: Basic or general health care usually rendered by general practitioners, family practitioners, internists, obstetricians and pediatricians -- often referred to as primary care practitioners. Professional and related services administered by an internist, family practitioner, obstetrician-gynecologist or pediatrician in an ambulatory setting, with referral to secondary care specialists, as necessary. Primary Physician Capitation The amount paid to each physician monthly for services based on the age, sex and number of the Members selecting that physician. Professional Standards Review Organization (PSRO) A physician-sponsored organization charged with reviewing the services provided patients who are covered by Medicare, Medicaid and maternal and child health programs. The purpose of the review is to determine if the services rendered are medically necessary; provided in accordance with professional criteria, norms and standards; and provided in the appropriate setting. Purchaser This entity not only pays the premium, but also controls the premium dollar before paying it to the provider. Included in the category of purchasers or payers are patients, businesses and managed care organizations. While patients and businesses function as ultimate purchasers, managed care organizations and insurance companies serve a processing or payer function. [ A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z ]