Description: Medicare-Advantage Organizations (MAOs) are often under intense pressure to increase revenue. The ACA dramatically changed the incentives by which MAOs achieve financial success. With benchmark rates growing only as fast as FFS Medicare rates, many MAOs rely on risk scores and quality bonuses as their primary source of additional revenue.There are a not insignificant number of MAOs that are either under scrutiny by federal investigators, exposed to whistleblower lawsuits, and some even paying large penalties to resolve False Claims Act liability for providing inaccurate risk adjustment information (e.g., $270 million paid by Healthcare Partners/DaVita Medical Holdings in October 2018).Is it possible to operate a risk adjustment program that is both compliant with applicable federal regulations and sub-regulatory guidance yet still generate the revenue to ensure that Medicare-Advantage plans are financially viable in the marketplace? The presenters believe that not only is true compliance (as opposed to the mere appearance of a compliance program) a requirement for success, it is a necessary pre-condition for both MAO profitability and to ensure that risk scores are an accurate representation of member morbidity.

Description: Recently researchers, practitioners, and regulators had intense debates about how to treat the data collection threshold in operational risk modeling. There are several approaches under consideration—the empirical approach, the “naive” approach, the shifted approach, and the truncated approach—for fitting the loss severity distribution. Since each approach is based on a different set of assumptions, different probability models emerge. Thus, model uncertainty arises. When possible we investigate such model uncertainty analytically, otherwise we use Monte Carlo simulations. For specific parametric examples we consider exponential and Lomax distributions which are special cases of the generalized Pareto family. Our primary goal is to quantify the effect of model uncertainty on risk measurements. This is accomplished by evaluating the probability of each approach producing conservative capital allocations based on the value-at-risk measure. These explorations are further illustrated using a real data set for legal losses in a business unit (Cruz, 2002).

Description: Come prepared for an engaging workshop where you will have the opportunity to share thoughts on and work through a variety of questions concerning how actuaries must adapt to account for newer underwriting and distribution practices. Seating will be limited for this workshop focused on life actuaries who price and set assumptions for products impacted by new underwriting tools and processes such as accelerated underwriting (AU) or direct-to-consumer (DTC) distribution.

Description: Insurance carriers are continually challenging to innovate and evolve emerging underwriting toolswisely. A growing number of new tools continue to emerge. Uncover insights and gaina technical understanding on two models from validation studies recently conducted. Find out more information on ways to evaluate models for bias an fairness. Perspectives will be shared from both a direct carrier and reinsurance standpoint. By attending the session, you will: Gain more insight into emerging underwriting tools and methods to evaluate them.

Description: An article from The Actuary that highlights the strategic importance of inter-company mortality studies. Broad-based mortality studies form the backbone of the life actuarial profession. However, few companies have sufficient exposure or deaths to construct their own mortality table. Even is some large companies have enough data, there is still a vast majority of companies that do not. Historically, the void has been filled by means of inter-company studies.

Description: This is a panel discussion session on health services companies - HMO, self-funded, PPO - compared to traditional health insurers the advantages and disadvantages, and long term prospects for survival associated with each type of carrier. From the Record of the SOA 1983 Vol. 9 No. 1

Description: Updates on the efforts of the Academy’s health practice council. its work groups and task forces, to conduct research and educate health care policymakers on issues including principles for market reform, individual insurance, and risk factors.

Description: This report provides actuaries and other professionals working with risk, data and analytics or program evaluation in the health care space with considerations and frameworks related to the use of determinants of health (DOH) in data and actuarial work streams. Such frameworks can leverage new data sources to enrich health care data analysis to move beyond traditional data elements, such as age, gender, zip code or health diagnosis.

Description: A divisive confrontation over health care pricing is almost inevitable over the next few years. What will ultimately happen is a political decision, not an actuarial one—but it will have major consequences for the trend in health care costs and the divergence between public and private insurance premiums.

Description: This panel focuses on the current social and economic issues of health insurance within Canada and the U.S., with particular issues in the United States. From Transactions of Society of Actuaries 1960, Vol. 12, No. 34.