Question 36

The member will pay more of the treatment cost.

Utilizing a physician outside of the Preferred Provider Organization (PPO) network typically results in higher out-of-pocket expenses for the member. This occurs because PPOs generally have negotiated rates with in-network providers, which do not apply when a member seeks care from an out-of-network physician.

A) The primary care physician has to authorize the treatment.

This option is incorrect as PPO plans do not require a primary care physician's authorization for seeing specialists or out-of-network providers. Members have the flexibility to seek care without needing a referral or prior approval.

B) PPO is a closed plan, no benefit would be available.

This statement is inaccurate because PPOs are not closed plans; they allow members to seek care from both in-network and out-of-network providers. While benefits may be reduced when using out-of-network services, some level of coverage is still available.

C) There is no affect on the member.

This option is false, as choosing to use an out-of-network physician does indeed affect the member financially. The member will incur higher costs compared to using in-network providers, which contradicts the claim that there is no effect.

D) The member will pay more of the treatment cost.

This is the correct answer, as members typically face increased out-of-pocket expenses when utilizing services from out-of-network providers. The higher costs stem from the lack of negotiated rates that apply to in-network providers.

Conclusion

The correct answer highlights the financial implications for the member when seeking care outside of their PPO network. Options A, B, and C fail to recognize the flexibility of PPOs and the associated costs, clearly establishing that using out-of-network services results in increased treatment costs for the member. Thus, D is the only accurate reflection of the situation.