1. In a medical center facility, doctor that is asked to do final decision-making in complicated or difficult cases by evaluating appropriateness of admission, judging efficiency of services for level of care and place of service, and in seeking appropriate care alternatives for selected patients. Additionally, a PA can act as a negotiator and educator with practicing physicians and as liaison between the utilization management company and the provider community in understanding and shaping more efficient and cost-effective medical practice. 2. Individual hired to improve the revenue cycle. Also called business consultant. 3. Individual who assists patients in selecting medical insurance and in choosing a physician.

Legal contract between an insurance company or managed care plan and a physician (participating physician) to give medical services to the plan’s members.

Health care professional academically, clinically prepared, and licensed to practice medicine with supervision and guidance of a licensed doctor of medicine or osteopathy. Depending on state laws, PAs perform the following: take medical histories, diagnose and treat conditions, order and interpret laboratory tests, perform physical examinations, assist in surgery, counsel patients, and prescribe, administer, and dispense medications. Training programs average 25 to 27 months. National certification is available to graduates of approved training programs, a master’s-degree level in most states. Also referred to as a physician extender (PE).

Partnership, association, or corporation composed of two or more physicians and/or nonphysician practitioners who wish to bill Medicare as a unit.

Signed and dated verification by the attending physician of the accuracy, completeness, and description of the patient’s principal and secondary diagnoses and procedures in a Medicare case. This document must be present in the patient’s medical record for each Medicare inpatient admission. It is necessary for diagnosis-related groups (DRG) assignment.

1. Process of verifying a physician’s medical education, training, and licenses so that a physician can be approved to practice in a hospital. 2. Process delegated by the board to the medical staff of medical staff appointment, reappointment, and delineation of clinical privileges. 3. From a health maintenance organization view, to credential physicians to ensure they have the right training and licensing and maintain information on their specialties.

Health care employee trained to provide medical care under the direct or indirect supervision of a physician (e.g., certified registered nurse practitioner, certified nurse midwife, physician assistant, occupational therapist, clinical psychologist, clinical social worker, clinical nurse specialist, physical therapist, certified registered nurse anesthetist). PEs might also include auxiliary personnel such as registered nurses, licensed practical nurses, technicians, medical assistants, and any other individual acting under a physician’s supervision. Some states specify certain supervision requirements such as physician telephone or on-site access, chart review/sign-off, and conferencing. Further information via the Internet is available at the websites of the American Association of Physician Assistants and the American College of Nurse Practitioners. The Centers for Medicare and Medicaid Services (CMS) refers to PEs as limited license practitioners (LLPs). Also referred to as nonphysician practitioner (NPP), midlevel provider (MLP) , or midlevel practitioner (MLP).

Partnership, association, corporation, individual practice association (IPA), or other group that distributes income from the practice among members. An IPA is considered to be a physician group only if it is composed of individual physicians and has no subcontracts with other physician groups.

Association between one or more hospitals and one or more physicians to assist in negotiation, contract development, administrative services, financial management services, and marketing of managed care plans for its members. The PHO may also undertake utilization review, credentialing, and quality assurance. Physicians have their own practices and continue their traditional business outside the PHO. Also called medical staff-hospital organization.