Description: The presenters give a history lesson on the origin of CMS Medicare star ratings, including why this demonstration was originally created and how the program has worked over the years. The discussion will cover both the evolution of the underlying measures and the financial impact to Medicare Advantage stakeholders. By attending the session, you will have a stronger understanding of how member experience and outcome-based measures can be factored into the funding within a health care system to better align incentives among various stakeholders.

Description: How do we take a Minimum Viable Products (MVP) approach to launch new insurance products? Join this moderated discussion and focus on three key development aspects: Distribution, Systems, and the design and pricing of the Insurance product itself. Come discuss reasons to choose an MVP approach and how it solves many of the product launch challenges.

Description: CPT, NCCI, ICD, CCI, DRG, APC, PTP – understanding healthcare claims involve a dizzying array of code sets and payment methodologies, and yet the claim form is the intersection of health plan affordability, provider payment, and data analysis. This webcast will cover: • The code sets used in medical coding • Types of correct coding policies implemented by CMS and commercial payers • Payment integrity strategies to drive health plan affordability • Data analytics approaches leveraging medical coding knowledge

Description: 2021 Life Meeting - Session 5F: Premium Leakage - How Outdated Claims Systems are Losing You Money 8.31.21 Recording

Description: As the size of the life reinsurance market in Bermuda has grown to over half a trillion dollars at the end of 2021, more and more actuaries are getting involved with this 21 square mile North Atlantic island in one way or the other. Come explore a fundamental understanding of the Bermuda solvency framework and an overview of its upcoming changes.

Description: Hot Topics in Setting Pension Return Assumptions is the third in a series, following Mathematics of Pension Return Assumption and Inflation, focusing on Effects, Forecasts, and Role in Pension Valuations. What time horizon is more appropriate for Capital Market Assumption (CMA) forecasts: mid-term or long-term time horizon, or a blend of both? How do we map the asset classes of a plan's own investment policy to the asset classes of investment forecasters' CMAs? If we use asset-smoothing for valuation assets, should we use market-driven expected returns or smoothed/average versions of them?

Description: With the mandated health plan transparency files, health plans and providers are now able to substantially enhance their provider contracting efforts. Although the files are large and cumbersome they are market disruptors and provide new insights for provider contracting efforts. Explore a demonstration on the type of information now available and how it can be used to enhance this from both a health plan and health care provider perspective.

Description: Review a recently completed research project for a multi-stakeholder data consortium on social determinants of health (SDOH). In this project, claims, external SDOH data, geospatial analysis, and machine learning models were used to examine several questions: How to identify SDOH vulnerabilities? How sensitive are the findings with respect to provider coding pattern variations? How much variability in cost can be explained by SDOH vs. morbidity? What are the key risk drivers revealed by machine learning models? The session will review the methodology and main findings from this project.

Description: This session explores the far-reaching changes to how clinical data will be sourced, processed and consumed in many payer use cases including risk adjustment, quality measurement, care management, claims adjudication, prior authorizations, and other payer functions. Robust, interoperable data exchange is a prerequisite for value-based care. Clinical data will be increasingly accessible to augment administrative (claims) data via standardized Fast Health Interoperability Resources (FHIR, pronounced 'fire'), at a fraction of the cost of a accessing a traditional medical record and in real-time. On May 1, 2020, HHS issued a final rule implementing interoperability and the patient access provisions of the 21st Century Cures Act of 2016, although enforcement has been delayed into 2021 because of the COVID-19 pandemic. The new regulations promote, “HHS’s vision and strategy for achieving a health information ecosystem within which all individuals, their personal representatives, their health care providers, and their payers are able to send, receive, find, and use electronic health information in a manner that is appropriate, secure, timely, and reliable to support the health and wellness of individuals through informed, shared decision-making, as well as to support consumer choice of payers and providers.”Once enforcement begins, CMS and the Office of the National Coordinator for Health Information Technology (ONC), have the authority to mandate adoption of interoperability requirements, and also penalize payers and providers for non-compliance or the delay and withholding of data.This ‘digital transformation’ of the clinical data ecosystem has far-reaching implications for enabling technologies including Natural Language Processing (NLP) and entire segments of services and vendors. It will eliminate many departmental barriers, duplication and error sources for health plans and impact every department and the underlying economics of delivering and managing care.

Description: Back in the day, when data was scarce and computers were slow, actuaries were forced to use simple methods to account for risk. By far, the most common method was to add a margin, usually 5% to a “best estimate” calculation. Remarkedly, this method still works quite well in the aggregate. The problem is that, in many cases, decisions today require a more in-depth analysis. For example, how big a risk is a health plan really taking if it lowers its premiums by 10% to attract more members? This session will discuss techniques for measuring risk in today’s environment. Speakers will also share the results from the 5/50 research project, which forms the foundation for the techniques.