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.

Answer and Explanation

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 C

Explanation

Choice A rationale

While receiving free lunches at school may indicate a low-income status, it does not necessarily suggest maltreatment at home. Many schools offer free or reduced-price lunches to students from low-income families to ensure they receive proper nutrition.

Choice B rationale

Urinary incontinence in a child could be due to various reasons, including medical conditions or stress. While it could potentially be a sign of maltreatment, it is not a definitive indicator and would need to be evaluated in the context of other signs and symptoms.

Choice C rationale

Frequent absences from school can be a potential sign of maltreatment at home. Children who are being maltreated may be kept home to hide physical signs of abuse, or they may be truant due to a lack of parental supervision or a chaotic home environment.

Choice D rationale

Being underweight for their age could be a sign of neglect, one form of maltreatment. However, it could also be due to a variety of other factors, including medical conditions or poor nutrition, and should be evaluated in the context of other signs and symptoms.

A. You should have a complete eye examination every 2 years until the age of 64. B. You should have your fasting blood glucose level checked every 6 years. C. You should have your stool tested for blood every other year until the age of 74. D. You should have your hearing screened every 5 years.

Correct Answer is A

Explanation

Choice A rationale

This is the correct answer. Regular eye examinations are important for early detection of eye diseases and conditions. The American Optometric Association recommends adults aged 18 to 60 have an eye exam at least every two years, and adults 61 and older have an eye exam annually.

Choice B rationale

Regular monitoring of blood glucose levels is crucial for individuals with diabetes or those at risk. However, the frequency of checking fasting blood glucose levels can vary depending on individual health status and risk factors.

Choice C rationale

Stool tests for blood are used to detect colorectal cancer. The American Cancer Society recommends that adults aged 45 and older with an average risk of colorectal cancer undergo regular screening with either a high-sensitivity stool-based test or a structural (visual) exam, depending on the patient’s preference and test availability.

Choice D rationale

Regular hearing screenings are important, especially as individuals age. However, the frequency of hearing screenings can vary based on individual risk factors and symptoms.

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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?

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