NHA Billing and Coding Specialist

In a capitated health maintenance organization (HMO), the payment structure is characterized by a flat fee provided to healthcare providers for each patient enrolled in the plan, rather than being based on the individual services rendered during a specific visit. This means that regardless of how many services the patient utilizes over a certain period, the provider receives a set amount of payment for that patient’s care. This model incentivizes providers to focus on preventive care and efficient management of resources, as they receive a predictable and stable income for their services, which can improve patient outcomes and reduce overall healthcare costs.

The other options do not accurately reflect the nature of a capitated HMO. Payment based on individual services rendered implies a fee-for-service model, which is not applicable in this case. The option indicating that patients can choose any provider does not align with the HMO model, as HMOs typically restrict members to a network of chosen providers. Lastly, stating that payment varies depending on the diagnosis contradicts the flat-rate payment structure inherent to capitated plans.