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Participating physician or Participating Provider - Simply refers to a provider under a agreement with a health plan. A physician or hospital that has approved to provide services for a set payment provided by a payer, or who agrees to other arrangements, or who agrees to provide services to a set of covered lives or defined patients.
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Patient Liability - The dollar amount that an insured is legally compelled to pay for services rendered by a provider. These may include co-payments, deductibles and payments for exposed services.
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Patient Origin Study - A study, in general undertaken by an individual health program or health planning agency, to determine the geographic distribution of the residences of the patients served by one or more health programs. Such studies help define catchment and medical trade areas and are useful to locate and planning the development of new services.
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Part A Medicare - Refers to the inpatient portion of benefits under the Medicare Program, to cover beneficiaries for inpatient hospital, home health, hospice, and limited skilled nursing facility services. Beneficiary is dependable for deductibles and copayments. Part A Medicare services are financed by the Medicare HI Trust Fund, which consists of Medicare tax payments.
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Part B Medicare - Refers to the outpatient benefits of the Medicare. Medicare Supplementary Medical Insurance (SMI) below Part B of Title XVII of the Social Security Act covers Medicare beneficiaries for general practitioner services, medical provisions, and other outpatient treatment. Beneficiaries are accountable for monthly premiums, copayments, deductibles, and sense of balance billing. Part B services are financed by a combination of enrollee premiums and all-purpose tax revenues.
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Part D Medicare- A stand-alone drug plan, available by insurers and other private companies to beneficiaries that receive their Medicare Part A and/or B benefits through the Original Medicare Plan. Medicare Private Fee-for-Service Plans that don't offer instruction drug coverage; and Medicare Cost Plans offering Medicare prescription drug coverage.
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Partial Capitation - A contract between a payer and a sub-capitor, provider or other payer whereby payments made are a mixture of capitated premiums and fee for service payments. The quantity of the ratios determines the amount of risk. Sometimes certain outliers are paid as fee for service while routine cares are capitated.
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Partial Hospitalization Program (PHP) - Acute stage of psychiatric treatment normally provided for 4 or more hours per day. Usually includes group therapies and activities with homogeneous patient populations.
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Partial Risk Contract - An agreement between a purchaser and a health plan, in which only part of the financial risk is transferred from the purchaser to the plan. Forms of this are frequently seen in "self-funded" plans, competitive bidding arrangements and new health plans.
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Participating Physician - A primary care physician in practice in the payer's managed care service area who has to enter into a contract.
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Participating Provider - Any provider licensed in the state of provision and constricted with an insurer. Usually this refers to providers who are a division of a network. That network would be a panel of participating providers. Payers collect their own provider panels.
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Pay-for-Performance Programs - A program of financially planned incentives for practitioners and providers in exchange or as reward for the achievement of certain benchmarks of performance. The hope is that by contributing positive rewards for both of reaching thresholds of performance and for making continuous strides in improving the quality of health care high quality health care will be delivered on a consistent basis.
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Peer Review - The mechanism used by the medical staff to assess the quality of total health care provided by the Managed Care Organization. The evaluation covers how well all health personnel perform services and how suitable the services are to meet the patients' needs. Normally, the evaluation by practicing physicians or other professionals of the effectiveness and efficiency of services ordered or performed by other members of the profession.
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Performance Measurement
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Performance Standards- Standards set by the MCO or payer that the provider will require to meet in order to maintain it's credentialing, renew its contract or avoid penalty. These will differ from payer to payer, and contract to contract. Standards an individual provider is probable to meet, especially with respect to quality of care. The standards may describe volume of care delivered per time period.
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Per Member Per Month (PMPM) - Applies to a income or cost for each enrolled member each month. Often used to explain premiums or capitated payments to providers, but can also refer to the revenue or cost for each enrolled member each month. Many calculations, other than cost or premium, make use of PMPM as a descriptor.
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Personal Representative - A person certified under state or other law to act on behalf of the individual in making health-related decisions. Examples comprise a court-appointed guardian with medical authority, a health care agent under a health care proxy, and a parent acting on behalf of an un-emancipated minor. For a decedent, the personal envoy may be an executor, administrator, or other authorized person.
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Per Thousand Members Per Year (PTMPY) - A general way of reporting utilization. The most ordinary example of hospital utilization, expressed as days PTMPY.
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Pharmaceutical Cards - Identification cards to issue by a pharmacy benefit management plan to plan members. These cards assist PBMs in processing and to track pharmaceutical claims.
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Pharmacy and Therapeutics (P&T) Committee - The MCO committee that develops, updates, and administers the MCO's formulary and frequently reviews reports on clinical trials, drug utilization reports, current and proposed therapeutic guidelines, and economic data on drugs.
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Pharmacy Benefit Management (PBM) Plan - A type of managed care specialty service organization that seeks to contain the costs of instruction drugs or pharmaceuticals while promoting more efficient and safer drug use.
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Physician Attestation - The requirement that the attending physician confirm, in writing, the accuracy and completion of the clinical information used for DRG assignment.
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Physician Contingency Reserve (PCR) - Portion of a claim to deduct and held by a health plan before payment is made to a capitated physician. Revenue that is withheld from a provider's payment to serve as an inducement for providing less expensive service. A typical withhold is around 20 percent of the claim. This amount can be paid back to the provider following study of his/her practice and service utilization patterns.
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Physician Current Procedural Terminology (CPT) - List of services and procedures to perform by providers, with each service/procedure having a unique 5-digit identifying code. CPT is the health care industry's standard for treatment of physician services and procedures.
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Physician-Hospital Organization (PHO) - An organization on behalf of hospitals and physicians as an agent. A legal entity fashioned by a hospital and a group of physicians to further mutual interests and to achieve market objectives. A PHO generally combines physicians and a hospital into a solitary organization for the purpose of obtaining payer contracts. PHOs may also own, function or subcontract MSOs, health plans or providers. A PHO is typically owned and governed jointly by a hospital and shareholder physicians.
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Physician Organization - This term describes physician linkages and alliances that is used to allow physicians to manage risk and capitation. Information systems, physician relationships, and financial addition 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.
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Physician Practice Management Company (PPMC) - A company that provides management and administrative support, frequently with capital for clinical expansion. The usual management fee is 15-30% of net revenue minus the non-provider connected clinic expenses. In most cases, gives physicians a long-term agreement to continue working in their practice and sometimes an equity position in the company.
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Physician Services - Services provided by an individual approved under state law to practice medicine or osteopathy. Physician services given while in the hospital that appears on the hospital bill are not included in this definition.
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Plan Administration - A term often used to explain the management unit with responsibility to run and control a managed care plan which includes accounting, billing, personnel, marketing, legal, purchasing, possibly underwriting, management information, facility maintenance, servicing of accounts. This group usually contracts for medical services and hospital care.
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Plan Document - The document that contains all of the provisions, conditions, and terms of operation of a pension or health or wellbeing plan. This document may be written in technical terms as differ from a summary plan description (SPD) that, under ERISA, must be written in a manner calculated to be understood by the average plan participant.
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Plan Funding - The method that an employer or other payer or purchaser uses to pay medical benefit costs and managerial expenses.
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Point-of-Service Plan or Point-of-Service Option (POS) - A health services to deliver the organization that offers the option to its members to choose to receive a service from participating or a nonparticipating provider. Generally the level of coverage is condensed for services associated with the use of non-participating providers. Managed care plan that specifies that those patients who go outside of the plan for services may pay additional out of pocket expenses.
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PPS Inpatient Margin - It is the measure that is compared with DRG based operating and capital payments with Medicare-allowable inpatient operating and capital costs. It is calculated by subtracting total Medicare-allowable inpatient operating and capital costs from total PPS operating and capital payments and separating by total PPS operating and capital payments.
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Practical Nurses - Practical nurses, also known as vocational nurses, provide nursing care and treatment of patients under the management of a licensed physician or registered nurse. Licensure as an approved practical nurse (L.P.N.) or in California and Texas as a licensed vocational nurse (L.V.N.) is required.
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Preadmission Testing - A utilization management and cost saving method that requires plan members who are planned for inpatient care to have preliminary tests, such as X-rays and laboratory tests, performed on an outpatient basis prior to admission.
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Pre-Authorization - A cost containment characteristic of many group medical policies whereby the insured must contact the insurer prior to a hospitalization or surgery and receive authorization for the service.
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Pre-Certification - Pre-admission review and approval of appropriateness and medical necessity of hospitalization or other medical treatment.
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Pre-Existing Condition, Preexisting Condition - A medical condition developed preceding to issuance of a health insurance policy that may result in the limitation in the contract on coverage or benefits. Normally this is defined as a health problem for which the new enrollee established health care services before the date that the new health plan benefit begins. Some policies exclude coverage of such conditions and the exclusion may maintain for a specific period of time or indefinitely.
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Preferred Provider Organization (PPO) - Some combination of hospitals and physicians that agrees to make particular services to a group of people, perhaps under contract with a private insurer. A health care delivery system that contracts with providers of medical care to give services at discounted fees to members. Members may seek care form non-participating providers but usually are financially penalized for doing so by the loss of the discount and subjection to co-payments and deductibles.
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Premium- Amount paid to a carrier for providing coverage under an agreement. A periodic payment by the insured to the Health Insurance Company or prescription benefit manager in trade for insurance coverage. It varies depending on health plan or drug formulary.
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Prepaid Capitation - A prospectively paid, fixed, annual, quarterly, or monthly premium per person or per family that covers particular benefits. A cost suppression alternative to fee-for-service usually employed by HMOs.
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Prepaid Group Practice - Prepaid Group Practice Plans involve multi-specialty associations of physicians and other health professionals, who agreement to provide a wide range of preventive, diagnostic and treatment services on a continuing basis for enrolled participants. A healthcare system that offered plan members for a wide range of medical services through a restricted group of providers in return for a monthly premium payment.
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Prepaid Health Plan (PHP) - Entity that either contract on a prepaid, capitated risk foundation to provide services that is not risk-comprehensive services, or contracts on a non-risk basis. In addition, some entities that meet the above definition of HMOs are treated as PHPs through special statutory exemptions.
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Prepayment A method of paying for the cost of health care services in progress of their use. A method providing in advance for the cost of prearranged benefits for a population group, through regular periodic payments in the form of premiums, dues, or contributions, including those contributions that are made to a Health and Welfare Fund by employers on behalf of their employees.
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Prevailing Charge, Prevailing Fee - One of the factors formative a physician's payment for a service under Medicare, or other plan, set at a percentile of customary charges of all physicians in the locality.
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Prevalence - The number of cases of disease, infected persons, or persons with some other quality, there at a particular time and in relation to the size of the population from which drawn. It can be a measurement of morbidity at a moment in time, the number of cases of hemophilia in the country as of the first of the year.
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Preventive Care or Preventive Services - Health care that emphasize prevention, early detection and early treatment, so it reducing the costs of healthcare in the long run. Health care that seeks to avoid or foster early detection of disease and morbidity and focuses on keeping patients well in addition to health them while they are sick.
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Primary Care - Basic or general health care usually to render by general practitioners, family practitioners, internists, obstetricians and pediatricians who are often referred to as primary care practitioners or PCPs. Professional and associated services administered by an internist, family practitioner, obstetrician-gynecologist or pediatrician in an ambulatory setting, with referral to secondary care specialists, as necessary.
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Primary Care Network (PCN) - A group of primary care physicians who divide the risk of providing care to members of a given health plan.
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Primary Care Physician (PCP) - The generalist such as a family practitioner, pediatrician, internist, or obstetrician. In a managed care organization, a primary care physician is answerable for the total health services of enrollees including referrals, procedures and hospitalization.
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Primary Care Provider (PCP) - The provider that serves as the early interface between the member and the medical care system. The PCP is usually a physician, preferred by the member upon enrollment, who is trained in one of the primary care specialties who treats and is liable for coordinating the treatment of members assigned to his/her plan.
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Primary Coverage Plan that pays its expenses without consideration of other plans, below coordination of benefits rules.
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Primary Physician Capitation - The amount paid to each physician monthly for services based on the age, sex and number of the Members to select that physician.
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Primary Source Verification - A process through which an organization validates credentialing information from the organization that formerly confer or issued the credentialing element to the practitioner.
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Principal Diagnosis - The medical condition that is ultimately resolute to have caused a patient's admission to the hospital. The principal analysis is used to assign every patient to a diagnosis related group. This diagnosis may differ from the admitting and chief diagnoses.
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Privacy - For purpose of the HIPAA Privacy Rule, privacy means an individual's interest in limiting who has access to personal health care information.
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Privacy Board - A board of members certified by the HIPAA Privacy Rule to approve a waiver of authorization for use and/or disclosure of identifiable health information. For research purposes, the Institutional Review Board may also purpose as the Privacy Board.
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Private Fee-for-Service Plan (Medicare) - A type of Medicare Advantage Plan in which the patient may go to any Medicare which approved by doctor or hospital that accepts the plan's payment. The insurance plan, rather than the Medicare Program, decides how much it will reimburse and what the patient pays for the services. In this pact, the citizen may pay more or less for Medicare-covered benefits.
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Professional Review Organization (PRO) - An organization that reviews which provides services to patients in terms of medical necessity professional standards and appropriateness of setting.
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Professional Standards Review (PSRO) - A physician sponsored organization charged with reviewing the services provided patients who are enclosed by Medicare, Medicaid and maternal and child health programs. The purpose of the evaluation is to determine if the services rendered are medically necessary provided in accordance with professional criteria, norms and standards; and provided in the suitable setting.
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Profile- To aggregate data in formats that display patterns of health care services over a defined period of time.
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Profile Analysis or Profiling - Review and study of profiles to identify and assess patterns of health care services. Expressing a pattern of practice as a rate for some of the measure of utilization of costs or services or outcome as functional status, morbidity, or mortality aggregated over time for a defined population of patients. This is used to evaluate with other practice patterns.
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Programs of All-Inclusive Care for the Elderly (PACE) - PACE combines medical, social, and long-term care services for weak people to help people stay independent and living in their community as long as possible, while still receiving medical care they need. PACE is available only in states that have chosen to present it under Medicaid.
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Prospective Payment System (PPS) - A payment method that establishes rates, prices or budgets before services are to render and costs are incurred. Providers which retains or absorbs the least portion of the difference between established revenues and actual costs. The Medicare system used to pay hospitals for inpatient hospital services based on the DRG classification scheme. Medicare's sensitive care hospital payment method for inpatient care. Prospective per-case payment rates are set at a level projected to cover operating costs in an efficient hospital for treating a typical inpatient in a given diagnosis-related group.
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Prospective Review - The review and potential authorization of proposed treatment plans for a patient before the treatment is implemented.
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Protected Health Information - Under HIPAA, this refers to individually certain health information transmitted or maintained in any form.
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Provider - Generally refers to a hospital or doctor who provides care. A health plan, managed care company or insurance hauler is not a healthcare provider. The lines are indistinct sometimes, however, when providers create or manage health plans. At this point, a provider is also a payer. A payer can be provider if the payer owns or manages providers, as with a number of staff model HMOs.
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Provider Excess - Specific or aggregate stop loss coverage extensive to a provider instead of a payer or employer.
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Provider Manual - A document which contains information concerning a provider's rights and responsibilities as part of a system.
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Provider Profiling The collection and study of information about the practice patterns of individual providers, physicians and hospitals.
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Provider Services Organization (PSO) - Defined by CMS as a public or private entity that is recognized or organized by a health care provider or group of affiliated providers that provides a considerable proportion of the services under its Medicare contract directly through the provider or group of affiliated providers. And in which the provider or affiliated providers directly or indirectly share significant financial risk and have at least a majority financial interest.
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Psychotherapy Notes - These comprise notes recorded by the health care provider who is a mental health professional during a counseling session, either by a private session or by a group. These notes are part from documentation placed in the medical chart and do not include prescriptions. Specific patient approval is required for use and disclosure of psychotherapy notes.
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Public Health Authority - A federal, state, local or tribal person or organization that is requisite to conduct public health activities.
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Purchaser - This unit 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 to manage care organizations. As patients and businesses function as ultimate purchasers, managed care organizations and insurance companies serve a processing or payer function.
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Purchasing Alliances - Locally based, privately operated by organizations that offer affordable group health coverage to businesses with fewer than 100 employees. Also known as to purchase pools, health insurance purchasing co-ops, employer purchasing coalitions, or purchasing coalitions.
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