Margo, age 35, was severely injured in an auto accident. She is covered under he
ID: 2568473 • Letter: M
Question
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 $1,000 calendar-year deductible 80/20 percent coinsurance, and an annual out-of-pocket maximum limit of $3,000. As a result of the accident, Margo incurred the following medical expenses $500 $24,000 S5,000 300 S1,200 Cost of ambulance to the hospital Hospital bill for a 3-day stay Surgery for broken leg Prescription drugs outside the hospital Physical therapy for the broken leg In addition, Margo could not work for 1 month and lost $4,000 in earnings a. Based on this information, how much will Margo collect for her injury if she receives medical care from healthcare 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 answerExplanation / Answer
Answer for question no.a:
Total bill is as follows:
First the deductible is to be paid ie., $1000.
Balance is $31,000 -$1,000
=$30,000.
20% of the 30,000 =6000. but out of pocket limit is $3,000. Therefore balance is to be paid by insurance provider.
amount received from the health care provider is $30,000*80%+$3,000.
=$27,000.
Answer for question no.b:
If the conditions of the policy cover the retreatment expenses also in 80/20 coinsurance, then she will get the pay from the health care provider.
Particulars Amount Cost of ambulance to the hospital 500 Hospital bill for a 3 day stay 24000 Surgery for broken leg 5000 Prescription drugs outside the hospital 300 Physical therapy for the broken leg 1200 Total approved costs 31000