CPB Certified Professional Biller Certification Practice Exam

What distinguishes an Exclusive Provider Organization (EPO) from other health plans?

1. Coverage for out-of-network providers

2. Lower premiums than PPOs

3. Higher deductibles

4. Use of a primary care physician for referrals

The correct answer is: Lower premiums than PPOs

The defining feature of an Exclusive Provider Organization (EPO) is that it typically does not cover any services from out-of-network providers, except in emergencies. This is in contrast to health plans like Preferred Provider Organizations (PPOs), which offer a wider network of options and often provide some coverage for out-of-network care. EPOs often have lower premiums compared to PPOs due to the more restrictive nature of their networks; members are incentivized to use providers within the network. This restriction generally leads to lower overall costs for the plan, which translates to lower premiums for the insured. While it is true that EPOs may have deductibles that vary, they are not specifically characterized by having higher deductibles relative to other plans. Additionally, EPOs do not require members to have a primary care physician or to get referrals to see specialists, which differs from managed care plans that do impose these requirements. Hence, the aspect of lower premiums distinguishes EPOs from other health plans in a significant way.