Description: CMS provides ACOs with monthly claims data for members, including their medical visits and ACO program eligibility. This data can be divided into Membership and Claims tables through the ETL process. However, when calculating PMPY at specific levels of detail using these tables, issues arise due to unrelated dimensions, leading to inaccurate and understated results. This article presents a solution to this problem by utilizing Tableau's data blending capabilities.

Description: Session 9B: Actuaries and Technology: Perspectives on Actuarial Workflow Automation The life insurance industry has experienced unprecedented growth in modernization efforts, with special attention paid to automating actuarial workflows. Companies are creating processes that are more scalable and maintainable, helping actuaries meet strict deadlines and deliver meaningful information to stakeholders. Discuss practical examples of automation, potential compositions of the modern actuarial toolkit, and different ways actuaries and technology teams interact during implementation and production states. Examine how automation can help actuarial teams shift from a quarterly to a monthly valuation process by overcoming challenges in traditional actuarial processes-long run times, the need for highly specialized legacy software skills, and inadequate control. Shifting to a monthly schedule can increase alignment on company objectives, deepen insurers' understanding of their business, and improve strategic decision-making. Leave with new ways of thinking about technology, from day-to-day best practices to full-scale actuarial transformation. By attending the session, you will: - Explain and understand the benefits of automating actuarial workflows with the purpose of operating on a monthly, rather than quarterly basis. - Describe the categories and purposes of several kinds of automation and supporting tools that might be used to accomplish this. - Understand different actuarial IT operating models and consider the application of such strategies at your organization. - Identify best practices for implementing automation based on the presented case studies.

Description: Every patient leaving the hospital has personal life-context circumstances that impact their chances of successful recovery and complications can be costly. Complex care management impacts over 50 percent of health care spend, with the admitted commercial population driving 37 percent of spend or $177M per 100,000 lives and the Medicare population driving 53 percent of spend or $600 million per 100,000 lives. The stakes are high, but existing care management solutions are mostly clinical and navigation call centers provide fragmented and outdated patient management systems, and do not address individual life-context. Discharged patients therefore remain underengaged and undercompliant, leading to costly complications. Innovative technology can help enable and integrate systems and existing infrastructure to leverage evidence-based contextualized care that will enhance care management, improve efficiency, and drive a better experience and outcomes for patients. This technology helps codifies life context, dynamically stratifying and engaging members digitally and telephonically helping virtual care teams to be more effective and efficient. In a recent randomized clinical trial, this technology and approach has shown a 50 percent reduction in the total cost of care, cutting the average and total cost of readmission, increasing virtual care team impact and member engagement and trust.

Description: Using the Internet as a Pricing Tool clinical background information, defining the change in coverage, collecting data, data quality and data limitations. Issue No. 39.