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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Related Questions
Correct Answer is D
Explanation
Choice A rationale
A consultant provides expert advice professionally. While a nurse case manager may provide advice as part of their role, arranging for the delivery of medical equipment to a patient’s home as part of discharge planning is not typically considered a consulting role19.
Choice B rationale
An advocate supports or recommends a particular cause or policy. While advocacy can be a part of a nurse case manager’s role, it is not the primary role being described in this scenario19.
Choice C rationale
A systems allocator distributes or spreads out something over a system. While a nurse case manager may allocate resources as part of their role, it is not the primary role being described in this scenario19.
Choice D rationale
This is the correct answer. A coordinator brings the different elements of a complex activity or organization into a relationship that will ensure efficiency or harmony. Arranging for the delivery of medical equipment to a patient’s home as part of discharge planning falls under this role19.
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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