Participating Hospital Agreement (PHA)
The contract between a hospital and Blue Cross Blue Shield of Michigan.

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 Advocate
An individual who investigates and mediates patients’ problems and complaints in relation to a health care provider’s services.

Patient Days
Refers to each calendar day of care provided to a hospital inpatient under the terms of the patient’s health plan, excluding the day of discharge.  Patient days is a measure of institutional use and is usually stated as the accumulated total number of inpatients (excluding newborns) each day for a given reporting period, tallied at a specified time (like midnight) per 1,000 use rate, or patient days/1,000.  Patient days are calculated by multiplying admissions by average length of stay (ALOS).

Patient Focused Care
A concept of patient care where health care providers are cross-trained, enabling greater coordination of care with fewer employees.

Patient Satisfaction Survey
Questionnaire used to solicit the perceptions of plan enrollees/patients regarding how a health plan meets their medical needs and how the delivery of care is handled.  (e.g., waiting time, access to treatments)

Payer
An organization (such as the federal government for Medicare or a commercial insurance company) or person who directly reimburses health care providers for their services.

Peer Review
Review of a health professional’s performance of clinical professional activities by peers through formally adopted written procedures.

Peer Review Organization or Professional Review Organization (PRO)
An organization with which the Medicare program and hospitals contract for quality and utilization review of services covered by the program.

Periodic Interim Payment (PIP)
A regular payment made by a carrier to a hospital, home health agency or skilled nursing facility that approximates anticipated revenue and is adjusted periodically to conform to actual revenues to assure predictable cash flow.

Performance Improvement
The continuous study and adaptation of functions and processes to increase the probability of achieving desired outcomes and better meet the needs of patients and other users of services.  (See Total Quality Management, Quality Improvement, and Quality Assurance.)

Pharmacogenomics
        The use of genetic information to tailor pharmaceuticals to specific patients.

Physical Therapist (PT)
An individual trained, licensed in, or practicing physical therapy.

Physician Assistant (PA)
A trained, licensed individual who performs tasks that might otherwise be performed by physicians or under the direction of a supervising physician.

Physician-Hospital Organization (PHO)
An entity sponsored and jointly governed by a hospital and a subset of its medical staff to negotiate and serve managed care contracts and achieve administrative efficiencies.

Physician Management Company (PMC)
An organization that provides physicians and physician groups with access to capital, information systems, group purchasing power, and management expertise.  May also establish management services organizations to develop relationships with physicians.

Physician Organization (PO)
Group of physicians representing various specialties or a single specialty which negotiates on behalf of its physician members to accept managed care or discounted fee-for-service contracts.  Also called multispecialty group or independent practice association (IPA).

Point-of-Service Plan (POS)
A model that combines features of both health maintenance organizations and traditional insurance.  Enrollees decide at the time care is needed whether to use a doctor who is in the network or one who is not.  Copayments and fee schedules are typically larger when a doctor outside the network is chosen.

Political Action Committee (PAC)
A body formed to collect and distribute contributions to political candidates.

Portability
The ability to move from job to job without losing health care benefits because of one’s health status or a pre-existing health condition.

Portable Benefits
A comprehensive set of health services that follow an individual regardless of his or her employment status.

Positron Emission Tomography (PET)
An imaging technique which tracks metabolism and responses to therapy.  Used in cardiology, neurology and oncology; particularly effective in evaluating brain and nervous system disorders.

Practice Guidelines
Formal procedures and techniques for the treatment of specific medical conditions that assist physicians in achieving optimal results.  Practice guidelines are developed by medical societies and medical research organizations, such as the American Medical Association (AMA) and the Agency for Health Care Policy and Research (AHCPR), as well as many HMOs, insurers and business coalitions.  Practice guidelines serve as educational support for physicians and as quality assurance and accountability measures for managed care plans.

Preauthorization
A method of monitoring and controlling utilization by evaluating the need for medical service prior to it being performed.

Pre-existing Condition
A medical condition existing prior to the effective date of insurance coverage.  Federal legislation passed in 1996 states that workers who are covered by group insurance policies cannot be excluded from coverage for more than 12 months due to a pre-existing medical condition.  Such limits can be placed only on conditions treated or diagnosed within the six months prior to enrollment in an insurance plan.  Insurers cannot impose new pre-existing condition exclusions for workers with previous coverage.

Preferred Provider Organization (PPO)
A type of health plan that features elements of fee-for-service and managed care.  The PPO contracts with networks of providers who agree to provide services and be paid negotiated rates.  Enrollees have lower copays and/or improved benefits if they see physicians and hospitals on the preferred list, which is created by insurance companies or employers.

Preventive Care
Comprehensive care emphasizing priorities for prevention, early detection, and early treatment of conditions, generally including routine physical examination, immunization, and well-person care.

Primary Care
Basic health care; a branch of medicine that accentuates the point when a patient first seeks assistance in a health care system and the treatment of simpler, more common illnesses and injuries.

Primary Care Physician
Physician in a managed care network who supervises medical care for members and makes referrals to specialists if needed.

Primary Diagnosis
The illness or injury causing most of the patient’s inpatient stay.

Principal Diagnosis (PDx)
After study, the diagnosis determined to be the major cause of a patient’s admittance to the hospital. This may or may not be same as the primary diagnosis.

Principal Procedure
The required procedure performed to treat a patient’s primary diagnosis.

Procedural Code
A statistical code system designed to communicate procedural data to insurance companies or other third-party payers.

Professional Corporation (PC)
A legal entity whose shareholders must be licensed members of the same profession, such as medicine or dentistry.  A PC provides limited liability for its professional stockholder(s) and allows for corporate ownership of equipment.

Prospective Payment System (PPS)
The Medicaid hospital payment system that sets payments in advance for the provision of the service.

Prospective Review
Part of the quality assurance process where possible hospitalization is reviewed, prior to admission, to determine appropriateness and medical necessity of the proposed level of care.  (See Quality Assurance.)

Provider Service Organization (PSO)
Organizations that provide community-based health care delivery systems as an alternative to fee-for-service insurance plans.  (See Community Care Networks.)

Provider Sponsored Network (PSN)
Formal affiliation of health care providers offering a full range of health care services with strong roots in the community.