Which situation is most likely to lead to the highest reimbursement for health care services used by a client?
1. A postoperative day 4 client is discharged a day earlier than expected.
2. The provider chosen is not within the provider network provided by the client's
point-of-service managed care organization.
3. The client has insurance coverage through a health maintenance organization (HMO), and seeks care from someone other than the primary care provider.
4. A client receives care from an extremely busy primary care provider who belongs to a medical group receiving capitated fees.
Answer: 1
Rationale: The client who is discharged earlier than expected will make money for the hospital because the money received for the client's diagnosis is based on the average inpatient time. The client who chooses to go out-of-network would have to pay the higher cost and possibly a service fee to the provider. The client with the HMO who goes somewhere other than the primary care provider will most likely have to pay for the entire visit out of pocket. Those providers working under capitation receive the same monthly fee regardless of the number of clients seen within that month. Thus, the busier the practice, the smaller the reimbursement per visit.
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