Medical Coding Lesson 3 (100+ Q&A) – Managed Care, Reimbursement Models, Risk Pools, Formularies | 2025/2026

This A+ graded and expert-verified study guide contains over 100 comprehensive questions and answers from Medical Coding Lesson 3, updated for the 2025/2026 academic year. It covers essential components of healthcare reimbursement, managed care models, and insurance structures, providing detailed insights into real-world healthcare financing systems and their impact on coding, billing, and healthcare delivery. Main topics covered include: Types of healthcare reimbursement: Fee-for-service (FFS), bundled payments, capitation, and episode-of-care models Managed care models: HMO, PPO, POS, EPO, and CDHP with comparisons based on referral requirements, premiums, provider networks, and patient flexibility Key roles and definitions: PCP (Primary Care Provider), specialist, network vs. out-of-network providers, referrals, gatekeeping, and participating providers Drug formularies: Tiered drug plans (Tiers 1–4), coverage policies, and committee approval processes for cost-effective prescription plans Utilization review: Prospective, concurrent, and retrospective service reviews, along with preauthorization procedures and quality assurance standards (QA, NCQA, HEDIS) Health plans & legislation: ERISA, CHAMPVA, TRICARE, COBRA, and managed care federal mandates Risk adjustment & reimbursement: Risk pooling, cost-sharing, insurance premium calculation, and incentive structures for cost efficiency Health records & documentation: EMR vs. EHR, problem-oriented record systems, and continuity of care via SOAP and integrated records Ideal for: Medical coding and billing students (CPC, CCS, CBCS) Health Information Management (HIM) and HIT programs Healthcare admin students focusing on payer systems and insurance structure Tutors and instructors seeking chapter-based testing and teaching material Organized in Q&A format, this guide helps build strong foundational knowledge for reimbursement-based questions on certification and classroom exams. Keywords: managed care, fee-for-service, bundled payments, capitation, HMO, PPO, EPO, CDHP, risk pools, PCP, referral, drug formulary, preauthorization, utilization review, EMR, EHR, HEDIS, NCQA, reimbursement, third-party payer