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8. (5 points) lmn company employees currently utilize two different networks. both networks use the same pharmacy benefits manager, and detailed pharmacy claims data are available. network a has additional detailed health claims information. the per capita claims cost for network a is twice as high as in network b. you have been asked to determine if the higher costs are caused by differences in the enrollee health status. (a) describe criteria used for health risk classification. (b) describe risk assessment models currently available. (c) recommend a risk assessment method for lmn company. 9. (7 points) you are an actuary who recently accepted a non-traditional role as claims manager for a health carrier. you are concerned about the new inventory standards, as measured by turn-around time (tat) and their impact on quality. additionally, you are concerned about common claims problems and the lack of documented procedures and guideline for working with other departments. (a) regarding tat: i. define tat. ii. describe considerations used when establishing tat goals. iii. describe the tools used for tracking and monitoring tats. (b) regarding quality: i. define the measures of claim quality. ii. list the steps of claim quality review process. iii. describe the major issues to consider when performing a quality audit. (c) describe common claims and benefit administration problems. (d) list the items requiring procedures and guidelines for coordination of the claim department with the following departments: i. enrollment and billing ii. provider relations iii. utilization management iv. member services v. finance course 8: fall 2004 - 7 - stop health, group life & managed care morning session 10. (4 points) as a result of the new medicare prescription drug improvement and modernization act of 2003 it may be necessary for a plan sponsor to perform an actuarial valuation to determine actuarial equivalence between the sponsor’s plan with the basic medicare benefit. assume that costs over age 65 for the sponsor’s plan are $1,500 per year and plan costs, on the average, increase by 3% per year above 65. assume that the demographics are as follows: demographics age group number 65 to 69 200 70 to 74 400 75 to 79 300 80 to 84 100 total 1,000 (a) outline the assumptions needed to perform an actuarial valuation of the sponsor’s plans. (b) develop the sponsor’s plan costs by age group. (c) describe the financial impact to the plan sponsor of the three possible outcomes when determining actuarial equivalence. **end of examination** morning session course 8: fall 2004 - 8 - go to next page managed care segment afternoon session **beginning of examination** managed care segment afternoon session beginning with question 11 11. (4 points) (a) describe the types of claim liabilities and reserves. for each, provide an example of an event which would require such a liability or reserves to be established. (b) describe common methods used to estimate claim reserves. 12. (6 points) company xyz management has decided it is time to invest resources into developing better reporting and analytical systems. (a) (2 points) describe ways data compiled in the claim adjudication process can be used for reporting and analysis. (b) (3 points) compare and contrast types of data structures and physical media used to store data in computer systems. (c) (1 point) describe considerations when choosing a data structure and storage media. course 8: fall 2004 - 9 - go to next page managed care segment afternoon session |
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