A nurse is collaborating with a case manager for a client who is part of a health maintenance organization. Which of the following payment structures does a health maintenance organization typically use?
The provider directly bills the client for a predetermined percentage of the cost of services.
The client pays the insurer a percentage of the total costs for each service provided.
The provider receives a fixed sum from the client on a monthly or yearly basis.
The client pays the provider directly for each individual service rendered.
The Correct Answer is C
Choice A rationale
While it’s true that some healthcare providers may bill clients directly for a predetermined percentage of the cost of services, this is not typically how health maintenance organizations (HMOs) operate. In an HMO, the provider usually has a contract with the HMO and receives payment directly from the HMO, not the client.
Choice B rationale
This choice describes a type of cost-sharing arrangement known as coinsurance, where the client pays a percentage of the total costs for each service provided. However, this is more characteristic of certain types of insurance plans, such as preferred provider organizations (PPOs), rather than HMOs.
Choice C rationale
This is the correct answer. In an HMO, the provider typically receives a fixed sum from the HMO on a monthly or yearly basis, regardless of the number of services rendered. This payment structure is known as capitation.
Choice D rationale
This choice describes a fee-for-service payment structure, where the client pays the provider directly for each individual service rendered. While this was a common payment method in the past, it is not typically used by HMOs. In an HMO, the provider usually receives payment directly from the HMO, not from the client.
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Correct Answer is D
Explanation
Choice A rationale
Identifying alternative solutions to address concerns is an important step in any project. However, it is not the first step in developing a mobile meal program for older adults who no longer drive. The first step should be to understand the needs of the target population, which can be achieved through a needs assessment.
Choice B rationale
Determining potential funding sources for the program is indeed a crucial aspect of planning. However, before seeking funding, it is essential to understand what needs to be funded, which comes from performing a needs assessment.
Choice C rationale
Inquiring about the availability of volunteers is a significant part of implementing the program. Volunteers could be responsible for meal preparation, delivery, or other tasks. However, the availability of volunteers does not determine the necessity or structure of the program.
Choice D rationale
Performing a needs assessment is the first step in developing a program. A needs assessment involves determining the extent of the need for a service in a particular population. In this case, it would involve determining how many older adults in the community no longer drive and would benefit from a mobile meal program.
Correct Answer is B
Explanation
Choice A rationale
A restorative aide is a healthcare professional who assists patients in regaining their abilities to perform the daily activities of life. They work with patients who have been debilitated by illness, injury, or age. While they can assist in general recovery following a stroke, they do not specialize in helping clients who are experiencing dysphagia.
Choice B rationale
A speech-language pathologist is a professional who diagnoses and treats communication and swallowing disorders in patients. Dysphagia, or difficulty swallowing, is a common complication of stroke, and speech-language pathologists are specifically trained to help these patients. Therefore, a speech-language pathologist would be the most appropriate resource for clients who are experiencing dysphagia following a stroke.
Choice C rationale
A physical therapist is a healthcare professional who helps patients reduce pain and improve or restore mobility. They often work with stroke patients to help them regain physical abilities. However, they do not specialize in treating dysphagia, which is a swallowing disorder.
Choice D rationale
An occupational therapist is a healthcare professional who helps patients develop, recover, improve, and maintain the skills needed for daily living and working. They can assist stroke patients in regaining their abilities to perform daily activities. However, they do not specialize in treating dysphagia.
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