Case study that requires presentation with analysis points based on client requirements
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Case study: Membership reporting: Accurate and timely reporting on membership is crucial for insurance organizations.
Terminology:
Period (aka month): calendar month
Benefit period: rolling 12 months from the start date of benefits (based on member/ group benefit selection)
Member-month: count of 1 for each member active in a month
Contract-month: count of 1 for each policy holder (primary beneficiary) active in a month
Case:
Acme Insurance Group (Acme) offers health insurance products in medical, dental, and vision lines. Benefits are offered by employer group segments as well as individual members. Gold, silver and Bronze plans are offered to individual members as well as employer accounts for the product. These levels differ in financial responsibility assigned to members for services they received. Products are priced by rate tiers (self, self+spouse, self+children, family, composite) to cater to all family units. As rates are negotiated at the time of purchase of policy, rates can differ from one customer to another for the same product. Individuals have the ability to purchase and enroll themselves and their family members in an insurance product through a web portal. Individual members are expected to wait for a period of 90 days before availing benefits. Individuals are automatically enrolled for the next benefit period in case they have not opted out before the end of their benefit period. Employer groups send membership data through files submitted in EDI standard. Employer groups send data weekly or monthly. It is very common that employers send membership data retroactively (that is date start date prior to current date). It is common that members in an employer group switch levels of benefits within a line of product within the same benefit period. Members can be enrolled into multiple lines of products at the same time, in which case they may have different start dates for different lines of products. Acme bills members for individually purchased products; and employer groups for group sponsored products. Bills are generated month in advance for each of the following months. As an insurance organization Acme is well aware of the age-based risk to their bottom line and would like to monitor that closely. Recently Acme observed urban migration of their population to large metros. The CEO would like to review the cost impact of this shift by member month, he is asking to find industry trends. The CEO would like to analyze persistence – as the cost retention seems to be much cheaper than cost of acquisition. Acme is a well-known partner-integrated organization in the USA with benefit coverage in all 50 states, hence, employer groups and individuals tend to stay with Acme for multiple years to take advantage of strong national provider networks. Each partner organization is an individual company that abides by the health insurance laws applicable for their state.
Acme uses Sureshot platform as their insurance ERP system. Acme is experiencing challenges in accurately reporting enrollment counts, largely attributed to retro-active changes. Source system is keeping archival of all changes that may help address this situation, but, physical deletes may be complicating this. Developers and DBAs have expressed concerns around large growth of membership data and data loss due to physical deletes. Users sometimes want to see as-of data and other times want current data.
Expectation:
While the case above provides general description and framing; you have freedom within set boundaries.
Approaches, thought process and presentation is as critical as representation of analysis points
Act as product owner/technical product owner/SME. Represent product to present reporting capabilities on membership data.
Infer from the case given above to help describe analysis capabilities. As an SME describe benefits of analysis.
Feel free to inject additional data points as an SME – provide references where these are injected
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