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P
Participating Physician
Top	A primary care physician in practice in the payer's managed care service area that has entered into a contract.
Participating Provider
Top	Any provider licensed in the state of provision and contracted with an insurer.
Patient Liability
Top	The dollar amount that an insured is legally obligated to pay for services rendered by a provider.
PCP Capitation
Top	Reimbursement systems for healthcare providers of primary care services that 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
Top	The mechanism used by the medical staff to evaluate the quality of total health care provided by the Managed Care Organization. The evaluation covers how well all health personnel perform services and how appropriate the services are to meet the patients' needs.
Per Diem Cost
Top	Cost per day; hospital or other institutional cost for a day of care.
Per Member Per Month (pmpm)
Top	Generally used by HMOs and their medical providers as an indicator of revenue, expenses, or utilization of services per member per one-month period; e.g., "we receive a capitation payment of $30 per member per month."
Per Member Per Year (pmpy)
Top	Generally used by HMOs and their medical providers as an indicator of revenue, expenses or utilization of services per member per year; e.g., Our patients come in to see the doctor on an average of 3.7 times per member per year.
Per Thousand Members Per Year (PTMPY)
Top	A common way of reporting utilization. The most common example of hospital utilization, expressed as days PTMPY.
Performance Standards
Top	Standards an individual provider is expected to meet, especially with respect to quality of care. The standards may define volume of care delivered per 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.
Physician attestation
Top	The requirement that the attending physician certify, in writing, the accuracy and completion of the clinical information used for DRG assignment.
Physician Organization (PO)
Top	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)
Top	It is owned jointly by a hospital and a physician group. The PHO, in turn, contract with hospitals and physicians for the delivery of services to payers under contract to the PHO. It can also provide management services and perform other services typically associated with an MSO.
Plan Administration
Top	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)
Top	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 co-pays than those using network physicians.
Practical Nurses
Top	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
Top	The American Medical Association defines practice parameters, as 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
Top	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.
Pre-authorization
Top	A method of monitoring and controlling utilization by evaluating the need for medical service prior to it being performed.
Pre-certification
Top	The process of notification and approval of elective inpatient admission and identified outpatient services before the service is rendered.
Predetermination
Top	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, co-payment 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, and prior authorization.
Pre-existing Condition
Top	(a) 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. (b) 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)
Top	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.
Premium
Top	A predetermined monthly membership fee that a subscriber or employer pays for the HMO coverage.
Prepaid Group Practice
Top	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
Top	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
Top	(a) Basic or general health care usually rendered by general practitioners, family practitioners, internists, obstetricians and pediatricians -- often referred to as primary care practitioners. (b) Professional and related services administered by an internist, family practitioner, obstetrician-gynecologist or pediatricians in an ambulatory setting, with referral to secondary care specialists, as necessary.
Primary Care Provider (PCP)
Top	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.
Primary Physician Capitation
Top	The amount paid to each physician monthly for services based on the age, sex and number of the Members selecting that physician.
Principal diagnosis
Top	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.
Professional Standards Review (PSRO)
Top	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.
Profile
Top	Aggregated data in formats that display patterns of health care services over a defined period.
Profile Analysis
Top	Review and analysis of profiles to identify and assess patterns of health care services.
Prospective payment system (PPS)
Top	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.
Prospective Review
Top	A method of reviewing possible hospitalization, prior to admission, to determine necessity of confinement, outpatient alternatives and estimated reasonable length of stay.
Purchaser
Top	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.

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