2004年11月SOA真题汇聚4Course8M（最后一课），北美精算师亲们一定要坚信自己的实力和能力。
　　18. (7 points) The Bedford Group is renegotiating 2004 provider contracts. The contracting
　　unit is proposing reimbursement increases to Hospital ID2 of 15% for Medical and
　　Surgical and 10% for all other services. In addition, the Medical Director has reviewed
　　Hospital ID2 Medical and Surgical charts and determined the following:
　　Chart Review Results
　　?  5% of admits are unnecessary
　　?  15% of days are unnecessary
　　?  Excess admits and days are evenly distributed between Medical and Surgical
　　services
　　Using Tables MC-2, MC-3, MC-4, and MC-7
　　(a) (3 points) Calculate the reimbursement for unnecessary care provided at Hospital
　　ID 2 for 2003. Show your work.
　　(b) (3 points) Forecast 2004 payments to Hospital ID 2 for medical and psychiatric
　　services that reflect:
　　?  proposed hospital reimbursement increases,
　　?  all potential utilization savings from the chart review,
　　?  budgeted utilization changes for psychiatric services
　　Show your work.
　　(c) (1 point) Describe issues regarding hospital claim submissions faced by MCOs
　　and claim review methods used to identify and address these issues.
　　COURSE 8: Fall 2004 - 14 - GO TO NEXT PAGE
　　Managed Care Segment
　　Afternoon Session
　　Questions 17 – 19 pertain to the Case Study
　　19. (7 points) As the CFO of the Bedford group you are concerned about the volatility of
　　Earnings Before Taxes as shown in Table MC-1. In addition to the information Table
　　MC-1, you are provided the following:
　　Membership Change None for 2004 or 2005
　　Expected 2004 Premium Increase 6%
　　Paid Claims Trend 10% per year for 2004 and 2005
　　IBNR Estimate 2.0 months of prior 12 months paid claims
　　Admin Trend 3% per year for 2004 and 2005
　　Average Premium Tax 1% of premium for 2004 and 2005
　　Investment Income Rate 3% per year for 2004, 4% for 2005
　　Corporate tax rate 0% for 2004 and 2005
　　Surplus at end of 2003 $350,000,000
　　Assume no changes to the 2003 Income Statement and Balance Sheet other than those
　　listed above.
　　(a) (6 points) The Board is expecting 2005 Operating Earnings to be 5% of premium.
　　Develop the overall 2005 premium increase needed to meet this goal.
　　Show your work.
　　(b) (1 point) Describe sources other than premium that can be used to increase
　　Operating Earnings.
　　COURSE 8: Fall 2004 - 15 - GO TO NEXT PAGE
　　Managed Care Segment
　　Afternoon Session
　　20. (3 points) You are the chief actuary for XYZ managed care company. You have
　　observed a very high trend in ambulatory care services and want to implement a series
　　reports to analyze and address this issue. Your Chief Medical Officer is concerned about
　　the reaction of providers to being profiled.
　　(a) List statistical considerations when choosing an ambulatory case mix system.
　　(b) Describe general types of reports you would develop for plan management of
　　provider costs.
　　(c) Define provider profiling, identify its uses, and list the principles your provider
　　profiling system will follow to ensure that the reports are fair and useful.
　　21. (4 points) You are an actuary for a health carrier that wants to add a disease management
　　program to help control costs and attract more self-funded employer business.
　　(a) Describe characteristics that contribute to a successful disease management
　　program.
　　(b) Describe barriers and drivers for implementation of a disease management
　　program.
　　(c) List the features that distinguish disease management from conventional medical
　　management.
　　(d) Explain potential risks involved with using the Internet as a disease management
　　tool.
　　COURSE 8: Fall 2004 - 16 - STOP
　　Managed Care Segment
　　Afternoon Session
　　22. (3 points) You are a consulting actuary assisting a group of physicians to determine
　　whether the group should form a fee for service or prepaid practice.
　　(a) Compare major risks for a prepaid practice relative to a fee for service practice.
　　(b) Outline alternatives the group could use to manage prepaid financial risk.
　　不大可能的事也许今天实现，根本不可能的事也许明天会实现。——高顿网校考试励志