Health / Health Insurance Glossary

Out-Of-Pocket Maximum: A predetermined limited amount of money that an individual must pay out of their own savings, before an insurance company or (self-insured employer) will pay 100 percent for an individual's . . . View Full Definition

Outcomes Measures: Healthcare quality indicators that gauge the extent to which healthcare services succeed in improving patient health.

Outpatient: An individual (patient) who receives health care services (such as surgery) on an outpatient basis, meaning they do not stay overnight in a hospital or inpatient facility. Many insurance com . . . View Full Definition

Outpatient Care: Treatment that is provided to a patient who is able to return home after care without an overnight stay in a hospital or other inpatient facility.

Parent Company: A company that owns another company.

Patient Bill Of Rights: Refers to the Consumer Bill of Rights and Responsibilities, a report prepared by the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry in an effo . . . View Full Definition

Patient Perception: A type of outcomes measure related to how the patient feels after treatment.

Peer Review: The analysis of a clinician's care by a group of that clinician's professional colleagues. The provider's care is generally compared to applicable standards of care, and the group's analysis . . . View Full Definition

Peer Review Organizations (Pros): According to the Balanced Budget Act of 1997, organizations or groups of practicing physicians and other healthcare professionals paid by the federal government to review and evaluate the se . . . View Full Definition

Pended: A claims term that refers to a situation in which it is not known whether an authorization has or will be issued for delivery of a healthcare service, and the case has been set aside for review.

Performance Measures: Quantitative measures of the quality of care provided by a health plan or provider that consumers, payors, regulators, and others can use to compare the plan or provider to other plans and providers.

Pharmaceutical Cards: Identification cards issued by a pharmacy benefit management plan to plan members. These cards assist PBMs in processing and tracking pharmaceutical claims. Also known as drug cards or presc . . . View Full Definition

Pharmacy And Therapeutics Committee: Committee charged with developing a formulary, reviewing changes to that formulary, and reviewing abnormal prescription utilization patterns by providers.

Pharmacy Benefit Management (PBM) Plan: A type of managed care specialty service organization that seeks to contain the costs, while promoting safer and more efficient use, of prescription drugs or pharmaceuticals. Also known as a . . . View Full Definition

Physician Practice Management (PPM) Company: A company, owned by a group of investors, that purchases physicians' practice assets, provides practice management services, and, in most cases, gives physicians a long-term contract to cont . . . View Full Definition

Physician Profiling: In the context of a pharmacy benefit plan, the process of compiling data on physician prescribing patterns and comparing physicians' actual prescribing patterns to expected patterns within s . . . View Full Definition

Physician-Hospital Organization (PHO): A joint venture between a hospital and many or all of its admitting physicians whose primary purpose is contract negotiations with MCOs and marketing.

Plan Administration: Supervising the details and routine activities of installing and running a health plan, such as answering questions, enrolling individuals, billing and collecting premiums, and similar duties.

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