ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 1 : Concepts and Trends in Health Care Questions
Question 1 of 5
A 72-year-old client who is hospitalized will be going on anticoagulant therapy and will require home healthcare nurses to visit once weekly to draw blood for coagulation studies. What coverage does the client have that will cover this service?
Correct Answer: B
Rationale: Medicare covers individuals who are 65 years of age or older, permanently disabled workers of any age with specific disabilities, and persons with end-stage renal disease. Medicare Part A covers hospital care, skilled care, hospice, and home health services. Medicare Part B covers medically necessary services such as physician services that are not covered under Part A. Medicare Part C is the Medicare Advantage Plan and includes Parts A and B. Medicaid coverage is coverage for indigent patients that are unable to afford healthcare and qualify financially.
Question 2 of 5
A 65-year-old client is prescribed multiple medications for diabetes, hypertension, and angina and is going to the pharmacy to have the prescriptions filled. What coverage will the client use to assist with financial coverage of the medication?
Correct Answer: D
Rationale: Medicare Part D is Medicare Prescription Drug Coverage and helps to cover and possibly reduce prescription drug costs and protect against catastrophic drug expenses. Medicare Part A covers hospital care, skilled care, hospice, and home health services. Medicare Part B covers medically necessary services such as physician services that are not covered under Part A. Medicare Part C is the Medicare Advantage Plan and includes Parts A and B.
Question 3 of 5
A group insurance plan requires a client to pay a present, fixed fee for healthcare services. What type of insurance plan does the nurse understand the client to have?
Correct Answer: B
Rationale: An HMO is a group insurance plan in which participants pay a preset, fixed fee in exchange for healthcare services. The fee is not based on the number of services provided but rather is projected to the number of participants and expected services. A PPO operates on the principle that competition can control costs. Acting as agents for health insurance companies, PPOs create a community network of providers who are willing to discount their fees for service in exchange for a steady stream of referred customers. Medicare is for people that are age 65 years and older or disabled. Medicaid is coverage for those clients who are unable to afford healthcare.
Question 4 of 5
An HMO client obtained a second opinion regarding a diagnosis of colon cancer. There was no authorization obtained for this second opinion from the client or primary care provider. What is the consequence of this action?
Correct Answer: A
Rationale: Members of an HMO must receive authorization for secondary care, such as second opinions from specialists or diagnostic testing. If members obtain unauthorized care, they are responsible for the entire bill. In this way, HMOs serve as gatekeepers for healthcare services. The member will not be fined or dropped from the program but will not receive coverage for the service rendered from the second opinion.
Question 5 of 5
What does the nurse understand is the focus of healthcare when a client receives services from a health maintenance organization (HMO)?
Correct Answer: B
Rationale: If the HMO does not require much high-cost care, providers make money; if members use many high-cost resources, providers lose money. This method of financing provides the strongest incentives for limiting use of expensive services and focusing healthcare on health maintenance and promotion. If services such as diagnostic testing are required, the HMO will cover this and not avoid payment. Services are not discounted for patients that are nonmembers or members. The goals of a physician hospital organization (PHO) are to maintain high-quality service and contain costs while fostering group contracts, collaboration, and capitation.