Margo, age 35, was severely injured in an auto accident. She is covered under her employer’s preferred provider organization (PPO) plan. The plan has a $1000 calendar-year deductible, 80/20 percent coinsurance, and an annual out-of-pocket limit of $3000. As a result of the accident, Margo incurred the following medical expenses:
Cost of ambulance to the hospital: $500
Hospital bill for a three-day stay: $24,000
Surgery for broken leg: $5000
Prescription drugs outside the hospital: $300
Physical therapy for the broken leg: $1200
In addition, Margo could not work for one month and lost $4000 in earnings.
A. Based on this information, how much will Margo collect for her injury if she receives medical care from health care providers who are part of the PPO network? (Assume that all charges shown are the allowable or approved charges by the insurer and all providers are in the PPO network.)
B. Assume that Margo’s broken leg does not heal properly, and she needs another surgical operation. Margo would like a different surgeon with an outstanding professional reputation to perform the operation. The surgeon is not a member of the PPO network. Will Margo’s plan pay for the surgery? Explain your answer.