Glossary of Health Care Terms
and Acronyms
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The definitions listed here are intended for a general understanding of a health care term. These definitions should not be considered as the complete definition, since many are written in the simplest form to give a general understanding of the term listed.
To look up a health care term such as Actuary, choose the letter that the term begins with below under Alphabetical Glossary. This will take you to the terms beginning with that letter. To look up a health care acronym such as AIDS, choose the letter that the term begins with below under Acronyms. This will take you to all acronyms that begin with that letter.
Alphabetical Listing
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
Acronyms
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
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| Paid Claims | The amount paid to providers to satisfy the contractual liability of the carrier or plan sponsor. These amounts do not include any member liability for ineligible charges, deductibles, or co-payments. |
| Paid Claims Loss Ration | The result of paid claims divided by premiums. |
| Paid-Up Policy | In long-term care insurance, it is generally the operation of a non-forfeiture feature under which the enrollee's coverage continues for some period based on the amount of premiums paid when the policy lapses. Methods for providing the paid-up policy may include full benefits for a shorter benefit period or partial benefits for the full original benefit period. Some policies also have a provision which pays up the policy under specified conditions upon the death of an insured spouse. Some companies offer limited or single payment premium modes that result in paid up policies when a specified number of annual premiums have been paid. |
| Palliative Care | Care which is provided to relieve pain rather than provide a cure. Also called "comfort care." |
| Partial Capitation | An insurance arrangement where the payment made to a health plan is a combination of a capitated premium and payment based on actual use of services; the proportions specified for these components determine the insurance risk faced by the plan. |
| Partial Hospitalization Services | A mental health or substance abuse program operated by a hospital that provides clinical services as an alternative or follow-up to inpatient hospital care. |
| Partial Risk Contract | A contract between a purchaser and a health plan in which only part of the financial risk is transferred from the purchaser to the plan. |
| Participant Driven Supports | Program in which an individual decides how limited funds, services, or other resources are used. Most commonly used in reference to attendants employed directly by a consumer who is responsible for, or has influence over, hiring, scheduling and firing. Also known as consumer directed care. |
| Participating Dentist | See participating provider. |
| Participating Hospital | See participating provider. |
| Participating Physician | See participating provider. |
| Participating Provider | A health care provider who has a contractual arrangement with a health care service contractor, HMO, PPO, IPA or other managed care organization. |
| Patient | Person who is receiving medical care. There are two types of patients, please seeinpatientor outpatientfor definitions. |
| Patient Advocate | Serves as a liaison between patient and hospital staff. Assists patients in interpreting hospital policies, procedures, and services and to obtaining solutions to problems and concerns. Assists staff in gaining awareness of patients' perceptions of the hospital experience. |
| Patient Origin Study | A study, generally 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 areas that are useful in locating and planning the development of new services. |
| Patient Protection Acts | Legislation that requires health benefit plans to take a number of steps to protect patient interests under managed care. The provisions of the acts vary according to state, but some of the most common require plans to disclose coverage provisions, benefits, exclusions, utilization review protocols and policies regarding specialist referral. Many of the acts ban language in provider contracts that may prevent physicians from discussing all treatment options (known as "gag" clauses), and require plans to disclose financial incentive plans for providers that may limit care and referrals and provide appeals processes for denied claims. Provisions may also require that individuals be given a choice between HMO, PPO and POS options, and that enrollees be allowed direct access to certain types of physicians, such as OB/GYNs. Plans can also be required to disclose their criteria for selecting and deselecting physicians and to provide due process for providers. |
| Patient Self-Determination Act | A Federal law that requires health care facilities to determine if new patients have a living will and/or durable power of attorney for health care and take patients' wishes into consideration in developing their treatment plans. |
| Payer | Generally regarded as the guarantor of payment. Could be an employer, health and welfare fund, insurer, or a broker for the employer or labor organization acting in a purchasing agent capacity, or an individual. |
| Payment Withhold | See risk contract. |
| Peer Review | The evaluation of quality of total health care provided by medical staff with equivalent training. |
| Peer Review Organization (PRO) | An entity established by the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) to review quality of care and appropriateness of admissions, readmissions and discharges for Medicare and Medicaid. These organizations are held responsible for maintaining and lowering admission rates, and reducing lengths of stay while insuring against inadequate treatment. |
| Per Capita Health Care Spending | Annual spending on health care per person. Per capita spending in 1997 was estimated at $3,925. |
| Per Case Payment | A set rate of payment for a hospital admission, including all ancillary services excluding separately billed physician services. |
| Per Diem Rate | A set price for one day of hospital care, including all ancillary services, excluding separately billed physician services. |
| Per Member Per Month (PMPM) | The amount of money paid or received on a monthly basis for each individual enrolled in a managed care plan, often referred to as capitation. |
| Percent of Premium | A predetermined percentage of premium is shared between the payer and provider to pay for the costs of medical services provided to the covered population. |
| Performance Measures | A mechanism to determine if a desired result has been achieved. See outcome measures, key indicators, and quality assurance. |
| 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. |
| Person Centered Planning | Process to identify and respond to the expressed needs and desires of an individual. Also known as personal futures planning or essential lifestyle planning. |
| Personal Attendant Services (PAS) | See attendants. |
| Personal Care | Optional Medicaid benefit which allows a state to provide services to assist functionally impaired individuals in performing the activities of daily living (e.g., bathing, dressing, feeding, grooming, etc.). See activities of daily living and attendant service. |
| Personal Care Advisor | See care coordination benefit. |
| Personal Care Advocate | See care coordination benefit. |
| Personal Emergency Response System (PERS or PRS) | A devise, carried or worn, that can be activated in an emergency to alert a central location through the phone system. Family, friends, or emergency services are then contacted to check on the nature of the emergency. |
| Personal Futures Planning | See person centered planning. |
| Pharmaceutical Care | A strategy that attempts to utilize drug therapy more efficiently to achieve definite outcomes that improve a patient's quality of life. A pharmaceutical care system requires a reorientation of physicians, pharmacists, and nurses toward effective drug therapy outcomes. It is a set of relationships and decisions through which pharmacists, physicians, nurses, and patients work together to design, implement, and monitor a therapeutic plan that will produce specific therapeutic outcomes. |
| Pharmacist | A health care professional who compounds and dispenses medications and other pharmaceutical supplies, using standard physical and chemical procedures to fill written prescriptions issued by physicians. Maintains records on all unit dose for each nursing unit and also IV additive program. Maintains inventory of supplies. Graduation from accredited school of pharmacy and licensed in the State of Delaware. |
| Pharmacy and Therapeutics (P&T) Committee | A group of physicians, pharmacists, and other health care providers from different specialties, who advise a managed care plan regarding safe and effective use of medications. The P&T Committee manages the formulary and acts as the organizational line of communication between the medical and pharmacy components of the health plan. |
| Pharmacy Services Administrative Organization (PSAO) | An organization that is dedicated to provide prescription benefits to enrollees of managed care plans that utilizes existing community pharmacies. The PSAO contracts as a provider group with the managed care organization, so that the individual pharmacies receive negotiating representation in numbers and the prepaid health plan does not have to provide the capital necessary to start, own, and operate their own pharmacy department. |
| Pharmacy Tech | Fills orders for prepackaged drugs or dispenses drugs from stock containers under the supervision of a pharmacist. In addition, the tech will fill routine orders for non-prescription drugs, replenish supply carts, and keep records on drugs delivered to the department and store incoming merchandise. |
| Physical Therapist | Assists patients who have experienced disability from illness, trauma, or birth defects, performs individual exercise programs to restore or relocate physical function. |
| Physical Therapy Assistant | Works under the supervision of a physical therapist. Duties include training patients in everyday activities, assisting patients in walking and exercising, and conducting treatments as prescribed by a physician. |
| Physician Assistant (PA) | A medically trained professional who can provide many of the health care services traditionally performed by a physician, such as taking medical histories and doing physical examinations, making diagnoses, prescribing and administering therapies. Also see mid level practitioner. |
| Physician Contingency Reserve (PCR) | See withhold. |
| Physician's Current Procedural Terminology (PCPT or CPT) | A list of medical services and procedures performed by physicians and other providers. Each service and/or procedure is identified by its own unique 5-digit code. CPT has become the health care industry's standard for reporting of physician procedures and services, thereby providing an effective method of nationwide communication. See HCFA common procedural coding system. |
| Physician Dispensing | A physician gives the patient his or her initial doses of a commonly prescribed drug during an office visit. The prescription is usually refilled at the pharmacy and not the physician's office. Doctors who dispense medications usually stock 20 to 30 drugs (antibiotics, anti-inflammatories, etc.). Pharmacists see this as a reduction in their marketshare, whereas physicians see this as both an extra service and convenience to their patients. |
| Physician-Hospital Organization (PHO) | A legal entity formed and owned by one or more hospitals and physician groups in order to obtain payer contracts and to further mutual interests; one type of integrated delivery system. |
| Physician Income | Net income after expenses and before taxes. |
| Physician Organization Arrangement (POA) | See physician hospital organization. |
| Physician Payment Review Commission (PPRC) | A bipartisan congressional advisory group established in 1986 to advise Congress on setting Medicare and Medicaid reimbursement. In 1990, PPRCs responsibilities were expanded to include other payment policy issues. |
| Physician Practice Management Company (PPMC) | A company that provides management and administrative support, often with capital for clinical expansion. |
| Physician Services | One portion of national health care expenditures. Includes physicians' overhead, administrative expenses, and income. |
| Plan for Achieving Self Support (PASS) | Option to exempt certain income used to improve independence from consideration in determining financial eligibility for disability payments under SSI. |
| Play or Pay Mandate | Employers are required to provide at least a minimum standard benefits package for their employees or pay a payroll tax. Employees in firms that choose to pay the tax will be "pooled" together for the purchase of health insurance either into a single public program like Medicare or a program in which enrollees choose from competing private health plans. Payroll tax revenues, individual premiums (with subsidies provided for low-income persons) and other general tax revenues would finance the health benefit costs. |
| Phlebotomist | Semi-skilled technician position involving the collection of blood specimens from patients through venipuncture. |
| Point of Purchase Plan | A benefit plan that expands enrollee options to choose providers. It usually consists of two or more delivery and financing options including an alternative delivery system, such as an HMO or PPO, and another plan such as traditional fee-for-service coverage. The participant is not locked-in but may change coverage options each time care is obtained. The scope of benefits and payment provisions are structured to provide incentives for greater use of the alternative delivery system option. |
| Point-Of-Service (POS) Plan | An insurance plan where members need not choose how to receive services until the time they need them, also known as an open-ended HMO. |
| Policyholder | Under a group plan, the group is the policyholder; under an individual plan, the individual is the policyholder. The policyholder is the one who has the contract or agreement with the insurer. |
| Political Action Committee (PAC) | A group of people organized to collect and distribute contributions to political candidates. |
| Portability | An individual changing jobs would be guaranteed coverage with the new employer, without a waiting period or having to meet additional deductible requirements. |
| Practice Expense | The cost of non-physician resources incurred by the physician to provide services. Examples include salaries and benefits for employees, the expenses associated with the purchase and use of medical equipment and supplies. |
| Practice Guidelines | A statement of what is known about the benefits, risks and costs of particular courses of medical treatment to achieve the best possible patient outcome. Also known as practice parameters. |
| Practice Parameters | Strategies for patient management developed to assist physicians in clinical decision-making. Parameters improve quality and assure appropriate utilization of health services. |
| Pre-Admission Certification | Review and approval process completed before hospital admission to ensure the medical necessity for the acute level of care and for the proposed services and procedures, to avoid a weekend admission, and to forecast the expected length of stay. The review process may include an assessment of the physician's proposed treatment protocol and fees. Compliance with changes in the treatment plan recommended by the reviewing entity may be a condition of receiving full coverage under the health benefit. The benefit level may be reduced or services not covered at all if the patient fails to comply with plan requirements. The pre-admission review process may also include an administrative confirmation of the patient's eligibility for benefits, covered services and restrictions, and the determination of applicable deductibles, co-payments, and maximums. |
| Pre-Admission Notification | Similar to pre-admission certification, a condition of receiving full benefits. Failure to notify the reviewing agency within the time limitations may result in a reduced level or denial of benefits. Differs from certification programs since the counseling offered by the notification agency is not binding upon the patient. |
| Pre-Admission Review | See pre-admission certification. |
| Pre-Admission Screening (PAS) | Process to determine the appropriateness of an applicant for nursing home placement. |
| Pre-Admission Screening and Annual Resident Review (PASARR) | Screening process for mental disabilities which assures that patients get the proper placement and access to services. |
| Pre-Admission Testing | Patient tests performed on an outpatient basis prior to admission to the hospital. |
| Pre-Authorization | Similar to pre-admission certificate, a condition of receiving health benefits. Review and approval process that must be completed before services are provided, when an inpatient or ambulatory site is proposed for care. The review process may include an assessment of the physician's proposed protocol and fees. Compliance with changes in the proposed treatment plan recommended by reviewing entity may be a condition of receiving full coverage under the health benefit. |
| Pre-Estimate of Cost | See pre-authorization. |
| Pre-Existing Conditions | When a physical or mental condition of a newly insured individual is present prior to the insurance of the new insurance policy. Normally, these exclusions last from 6 to 12 months, however, more severe conditions may be considered as lifetime exclusions. |
| Pre-Existing Condition Exclusion | Practices of some health insurers to deny coverage to individuals for a certain period, for health conditions that already exist when coverage is initiated. |
| Pre-Service Review | Pre-service review programs examine the medical necessity and appropriateness of proposed services to be provided in the ambulatory or inpatient setting that may require frequent treatment, extended courses of treatment, or require the use of expensive technologies. Dental and vision benefits may require predetermination for certain services or charges. |
| Predetermination | A procedure where a provider submits a treatment plan to the health insurer before treatment begins. The insurer reviews the treatment plan and notifies the provider of one or more of the following: patient's eligibility, covered services, amounts payable, co-payment and deductibles and plan maximums. |
| Preferred Provider Organization (PPO) | Contractual arrangements among hospitals, physicians, employers, insurance companies, or third-party administrators to provide health care services to subscribers at a negotiated, often discounted, price. |
| Preferred Providers | Physicians, hospitals, and other health care providers who contract to provide health services to persons covered by a particular health plan. |
| Premium | Prospectively determined rate for insurance coverage for specific health benefits. Generally, a health insurance plan will have different premium rates for single subscribers, married subscribers and for subscribers with dependants. |
| Premium, Community-Rated | Premiums based upon the claims experience of all those insured by the carrier and not dependent upon the claims experience of each policyholder. See community rating. |
| Premium Cost Sharing | The sharing of the cost of the health plan premium between the employer or other group sponsors and the enrollees. |
| Premium, Experience-Rated | Premium based on the projected utilization and claims experience of a specific group. See experience rating. |
| Premium Support | Public subsidy to purchase private insurance. |
| Premium Tax | A state tax levied on commercial insurance premiums. |
| Prenatal Care | Services to pregnant women designed to insure that both expectant mother and the newborn are in the best health. A lack of prenatal care early in the pregnancy is associated with low birth weight and infant mortality. |
| Prepaid Health Plan (PHP) | In Medicaid terminology, a PHP is not the same as an HMO even though the terms are often used interchangeably in commercial managed care business. PHPs can contract on a capitated basis for a non-comprehensive set of services (which is often called partial capitation) or on a cost basis. Federally qualified health centers (FQHCs) can also be designated as PHPs if they meet certain conditions. Also see sub-capitation. |
| Presumptive Eligibility | See eligibility guarantee. |
| Prevalence | The number of all new and old cases of a disease in a defined population at a particular point in time. |
| Preventive Care | Comprehensive care emphasizing priorities for prevention, early detection and early treatment of conditions, generally including routine physical examination and immunizations. |
| Primary Care | Entry-level care which may include diagnostic, therapeutic or preventive services. |
| Primary Care Case Management (PCCM) | Medicaid managed care option allowed under section 1915(b) of the Social Security Act in which each participant is assigned to a single primary care provider who must authorize most other services such as specialty physician care before they can be reimbursed by Medicaid. See gatekeeper. |
| Primary Care Network | A plan similar to an HMOwhich provides health services for a fixed price, relying on participating primary care physicians to serve as "gatekeepers" to control patient access to institutional services and specialty care. The primary care physician determines the patient's need for specialty care and any resulting referrals. |
| Primary Care Physician (PCP) | A physician designated as responsible to provide specific care to a patient, including evaluation and treatment as well as referral to specialists. |
| Primary Coverage | That coverage which pays first when an individual is covered under two or more insurance plans. |
| Prior Approval | An authorization for the delivery of services that must be obtained prior to the delivery of those services. Commonly used in the Medicaid program and managed care plans. See Medicaid,managed care, and utilization review. Also called prospective review or re-approval. |
| Prior Authorization | See prior approval. |
| Private Duty Nursing | Medicaid term to refer to covered skilled nursing services provided in the home. |
| Probationary Period | See Waiting Period. |
| Process Audit | A type of patient/medical care evaluation study in which the criteria are designed to focus on the components of appropriate clinical intervention. |
| Professional Liability Insurance | The insurance physicians purchase to help protect them from the financial risks associated with medical liability claims. Also known as malpractice insurance. |
| Professional Review Organization (PRO) | An organization that reviews the activities and records of a health care provider, institution, or group. The reviewer is generally a physician if a physician is the subject of the review; a group of administrators, physicians, and allied health care personnel if a hospital is the subject of the review; etc. The PRO can be state-sponsored or independent. |
| Profile Analysis | See profiling. |
| Profiling | An analytic tool that uses epidemiologic methods to compare practice patterns of providers on the dimensions of cost, service use, or quality of care. The provider's pattern of practice is expressed as a rate aggregated over time for defined population of patients. |
| Program of All-Inclusive Care for the Elderly (PACE) | A combination MedicareWaiver/Medicaid Waiver that provides day health center-based comprehensive community and medical services. PACE capitates primary, acute and long term care services exclusively for frail dual eligibles at risk of institutionalization. |
| Proportion Rules | The 75/25 Rule and the 50/50 Rule refer to references in Federally statutory requirements for enrollment composition in a full-risk Medicaid or Medicare program. The 75/25 Rule states that an HMO or HIO that has a Medicaid comprehensive risk contract cannot have more than 75 percent of its total enrollment be a combination of Medicaid and Medicare risk enrollees. PHPs sponsored by FQHCs are exempt from the 75/25 Rule. The 50/50 Rule states that an HMOor CMP that has a Medicare risk contract cannot have more than 50 percent of its total enrollment be a combination of Medicaid Medicare enrollees. |
| Proprietary Hospital | An investor-owned hospital operated for the purpose of making a profit for its owner. |
| Prospective Payment Review Commission | An independent body established by Congress to advise it on Medicare policies for reimbursing physicians. |
| Prospective Payment Assessment Commission (ProPAC) | A Federal commission established under the Social Security Act amendments of 1983 to advise and assist Congress and the DHSS in maintaining and updating the Medicare prospective payment system. |
| Prospective Payment System (PPS) | A method of financing health care that mandates payments in advance for the provision of services and is based on diagnostic related groups. |
| Prospective Pricing | Method of third party payment by which prices for services are established in advance for a specified period of time. These prices are firm regardless of the actual costs incurred in a specific episode of care. |
| Prospective Review | See prior authorization. |
| Provider | Generically, a professional engaged in the delivery of health services, including physicians, dentists, nurses, podiatrists, optometrists, clinical psychologists, etc. Hospitals and long term care facilities are also providers. The Medicare program uses the term "provider" more narrowly, to mean participating institutions: hospitals, skilled nursing facilities, home health agencies, etc. |
| Provider Reimbursement Review Board | A Federal board responsible for making decisions regarding provider appeals on Medicare reimbursement issues. |
| Provider-Services Network | See provider-sponsored organizations. |
| Provider-Sponsored Organization (PSO) | A provider-owned entity that is certified by HCFA to participate in the Medicare + Choice program and to assume risk for benefits provided to Medicare beneficiaries. Also referred to as Provider Services Organizations. |
| Pryor Bill | See Medicaid Prudent Pharmaceutical Purchasing Act. |
| Public Health Service | A Federal agency responsible for public health services and programs including biomedical research. |
| Pure Premium | The costs of claims for covered services for eligible individuals under a health insurance contract. This does not include administrative and other insurance costs included in the total costs incurred by an insurer under a contract. |