Chapter 09: Case ManagementNies: Community/Public Health Nursing, 7th Edition

1. A health care provider has charged more than what is allowed by a third-party payer. Which would most likely be the result? a. Provider may be removed from the list of providers for the third-party payer. b. The third-party payer will reexamine the payment for that procedure. c. Provider would get the typical payment instead of what was charged to the third-party payer. d. The third-party payer would be forced to increase its typical payment for that procedure. ANS: C Client service use reflects a greater emphasis on health care costs. Third-party payers evaluate the appropriate use and costs of health care resources. Therefore, at least on the first occasion, the most probable result would be that the provider gets the listed payment, not what the provider charged. DIF: Cognitive Level: Apply (Application) 2. A nurse is explaining case management to a client. Which statement would be the most appropriate for the nurse to make? a. “We assess, plan, facilitate, and advocate to save money as much as possible.” b. “We coordinate your care so you obtain needed services without incurring undue costs.” c. “We seek the lowest cost provider to give you what care is necessary.” d. “We collaborate with you to coordinate your care for the best outcome.” ANS: D There is no single definition of case management. But it is a collaborative process to meet an individual’s health needs through communication and available resources to promote quality cost-effective outcomes. The response “with you” shows a collaborative approach to coordinating care for the best outcome. DIF: Cognitive Level: Apply (Application) 3. A hospital is going to start a care management program. Which group of clients would most likely be selected to first receive such services? a. Clients who represent the most common diagnosis group to be admitted b. Clients who request such services from their local hospital c. Clients with chronic illnesses d. Clients with the leas