Description: Through the sponsorship of the Robert Wood Johnson Foundation, The Society of Actuaries partnered with Wakely to use their health care data to study the effects of COVID-19 on overall health care claims for individuals with a COVID-19 diagnosis. The conclusion of the study is that individuals with COVID-19 claims had significant increases in health care costs leading up to their months of diagnosis, as well as in the months following their diagnosis. These effects were more pronounced for individuals who were hospitalized due to COVID-19 as well as for individuals with prior co-morbidities. Finally, the overall health care costs of these members plateaued at significantly higher levels than their pre-COVID baselines. In fact, all the main membership cohorts experienced claim levels that were at least 20% higher than their pre-COVID starting points.

Description: This research report provides an evaluation and synthesis of the methodologies and data samples used on characterizing health care fraud.

Description: The SOA’s research objective is to provide guidance to state exchange officials and administrators, federal officials and administrators, and actuaries assisting states and health plans. The goal of the project is to estimate the morbidity and/or cost for newly insured individuals in the individual market (and to some degree, the small group exchange) relative to the morbidity and/or cost for the current commercially insured population. This analysis will primarily focus on the individual, non-group market. In order to plan for the impact that these currently uninsured individuals will have on the health insurance markets, it will be important to understand their costs relative to the costs for people already enrolled, for whom many health insurers have experience and data.

Description: A research report that first defines ERM and provides the results of an applicable literature search with hyperlinks and then describes the current state of Enterprise Risk Management practices for health organizations. Areas covered: 1. Operational Risks. 2. Balance sheet risks. 3. Pricing discipline. 4. Asset risks. 5. Learnings. 6. Emerging risks.

Description: A research report describing aspects of provider network performance in health care settings with particular focus on experiences with Exchanges.

Description: The Health Section Research Team is pleased to make available the following research study and Excel model that provide a framework for estimating the financial impact of health plan provider network risk. The research was conducted by the Denver office of Milliman, Inc. The Excel workbook allows the user to assess cost implications of aspects of network risk under various assumptions. The assumptions in the workbook can be altered by the user and be applied to test a range of scenarios.

Description: This is an Excel workbook that can be used as a tool for health insurance companies to model their potential risk exposure from an influenza pandemic. It is based on a model developed for a Society of Actuaries study examining the potential implications of a pandemic on the U.S. health insurance industry. The spreadsheet is saved with many of the same assumptions used in this research and reproduces the results of the exhibits contained in the June 2010 report, 'Potential Impact of Pandemic Influenza on the U.S. Health Insurance Industry.'

Description: This report outlines a framework for interpretable machine learning algorithms for detecting fraud in health insurance. It discusses the challenges of using black-box machine learning models in the insurance industry and proposes various interpretable methods to enhance transparency and understanding.

Description: This research material provides an evaluation and synthesis of the methodologies and data samples used on characterizing health care fraud