Actuarial Modeling’s Tools & Services


Actuarial Modeling has developed numerous actuarial and financial modeling tools specifically designed to facilitate the complex analyses required of effective managed care organizations.

Several tools developed and frequently used by Actuarial Modeling include the following:


I. RECASTER”The “Recaster” is a sophisticated and versatile Incurred But Not Paid (“IBNP”) estimation tool capable of managing up to 100 IBNP claim lag reports in a single Excel workbook.  The same Excel workbook accommodates up to 50 Scenarios of any combination of the 100 potential  claim lag reports. While a set of 16 default Scenarios are developed with the click of a single button (with the median Scenario highlighted), the User can customize hundreds of potential scenarios from the Recaster’s vast array of parameter options (i.e. completion factor methodologies, medical trend methodologies, claim inventory methodologies, claim anomaly adjustments, seasonality factors, hospital authorizations / physician referrals, etc.). Recaster data can be “exported” to the Segmenter (see below).

As with most all our tools, Recaster Scenarios can be readily Saved, Retrieved, and Deleted (and in the case of the Recaster, aggregated).


II.       CLAIM LAG & MEMBER EXPORTER” (“CLME”) – “CLME” is an Access Database Manager that accommodates large files of individual claim payments. CLME summarizes, formats, and exports the individual claim payments into industry standard Claim Lag Reports (i.e. Claim Triangles). CLME also summarizes, formats, and exports inforce membership files, using any of three User-defined methodologies (e.g. beginning of month, end of month, and average monthly inforce methods).  Both the Claim and Membership summary files are readily exportable into a Companion Excel Workbook, which, in turn, can export the summary information for up to 100 individual Market Segments into the RECASTER (please see tool II. above) via the single click of a Mouse Button.


III.       “SEGMENTER” – The “Segmenter” integrates the recast data from the “Recaster” to provide some of the required input data. The “Segmenter” is a tool used to capture, aggregate, and monitor current and historical trends of reported financial results by Market Segment. The Segmenter prepares summary reports with key financial indicators for both reported and recast (e.g. updated with current IBNP estimates) financial data. The Segmenter prepares up to 36 months of information for up to 50 Market Segments in a single Excel workbook.  Actuarial Modeling refers to this as a Market Segment Financial Analysis (“MSFA”).  Segmenter data can be “exported” to the Optimizer (please see tool V. below).

As with most all our tools, Segmenter Scenarios can be readily Saved, Retrieved, and Deleted (and in the case of the Segmenter, aggregated).


IV.        “OPTIMIZER” – The “Optimizer” integrates the recast data from the “Segmenter” to develop a comprehensive set of financial projection and capital planning reports.  The “Optimizer” offers a wide array of potential uses, including: Financial Planning, Capital Planning, Performance Measurement, Due Diligence, and Premium Deficiency Reserve Analysis. In addition, the Optimizer is an effective Financial Training Tool and, in the hands of a competent actuary, will accommodate all of the analytical requirements of a formal Actuarial Appraisal.

As with most all our tools, Optimizer Scenarios can be readily Saved, Retrieved, and Deleted.


V.       “CAPITALIZER” – The “Capitalizer” is a significantly more robust version of the National Association of Insurance Commissioner’s (“NAIC”) Risk-Based Capital (“RBC”) Forecasting Model for Health Care Companies.  Capable of storing, aggregating and allocating Risk-Based Capital requirements and Total Adjusted Capital for up to 50 Scenarios, or Market Segments in a single Excel workbook. The Capitalizer also provides helpful assumptions when analyzing capital targets via the Optimizer.

As with most all our tools, RBC Scenarios can be readily Saved, Retrieved, and Deleted (and in the case of the Capitalizer, aggregated and/or allocated).


VI.     “FEE-EVALUATOR” – The “FeeEvaluator” prepares detailed physician fee schedule comparisons with no practical limit for the number of CPT codes that can be analyzed. Compare your fee schedule with Medicare’s fee schedule for your area, evaluate the impact of changes to your fee schedule, or compare your fee schedule against a known competitor’s schedule (missing fees will automatically be extrapolated).

The FeeEvaluator can be used to evaluate either a virtually unlimited number of specific fee schedules or an entire network in one fell swoop by developing average fees per CPT from a Company’s detailed claim data file.

As with most all our tools, fee schedules can be readily Saved, Retrieved, and Deleted.


VII.    “HOSP-EVALUATOR” – The “HospEvaluator” evaluates hospital contracts and prepares objective PMPM estimates for both Inpatient and Outpatient Hospital Services. Inpatient PMPM estimates are developed from either detailed DRG-specific schedules or summarized aggregated unit costs by “Hospital Bed Day Type”. Similarly, Outpatient PMPM estimates are developed from either detailed Ambulatory Payment Classification (“APC”) schedules or summarized aggregated units costs by “Hospital Case Type”.

In addition to industry data for commercial unit cost and utilization PMPM analysis, the HospEvaluator comes with the most current Medicare DRG and APC-specific base data. Of course, the HospEvaluator also accommodates Company-specific data.

The HospEvaluator also contains a stop-loss analytical feature that evaluates PMPM costs on a “pre” versus “post” stop loss basis. All of the industry standard stop-loss permutations have been incorporated into the HospEvaluator (e.g. “Billed” vs “Allowed” triggers, reversion to percent of Billed Charges vs reversion to Fixed Per Diem vs reversion to minimum of Billed Charges / Fixed Per Diem, reversion to first dollar of admission vs reversion to excess over stop-loss limit).

As with most all our tools, the hospital contract evaluations can be readily Saved, Retrieved, and Deleted. This enables the User to readily evaluate the PMPM for an entire provider network of hospital contracts.


VIII. “RxEVALUATOR” – The “RxEvaluator” analyzes prescription drug information at the claim detail level. The RxEvaluator comes standard with the capability of analyzing such items as paid claims, allowed claims, payments at the Average Wholesale Price (“AWP”) level, average discounts, and various cost sharing parameters (i.e. copay amounts, coinsurance amounts, and deductible amounts). The analyses are prepared for each of various prescription drug types; e.g. Brand Preferred, Brand Non-Preferred, Generic, Retail, Mail, Specialty Drugs, etc.

In addition to the above-noted summary analyses, the RxEvaluator also prepares continuance tables for prescription drug claim payments.

Additionally, the RxEvaluator prepares various demographic analyses.


IX.        UNDERWRITING TOOLS – Actuarial Modeling offers an array of Underwriting Tools from monitoring an entire block of group business to the detailed underwriting of individual large groups. The array of Underwriting Tools includes but is not limited to:

A. Block Underwriting Rating & Monitoring – A methodology used to develop renewal rates, monitor manual rate accuracy, and project the financial experience of a block of group business.

B. “UnderMod_Tables” – “UnderMod_Tables” consists of a Microsoft Access-based tool to manage detailed claim and membership files and a companion Excel Workbook used to capture summary tables. Tables developed by UnderMod_Tables include:

 (1) Claim Continuance Tables: UnderMod_Tables develops User-defined continuance tables from detailed individual claim records. The User can choose to develop the continuance tables using either Paid or Allowed claims. The User also defines the time period for the continuance tables (e.g. incurred in twelve-months / paid in fifteen-months).

 (2) Demographic Summary Tables: UnderMod_Tables also develops the following two Demographic Summary Tables:

 (a) Age/Gender Summary Table: This table summarizes detailed member data as of a User-defined date by Employee, Spouse, and Child into defined age ranges by gender. Consistent with standard rating methodologies, the members are summarized by the employees’ age.

 (b) Family Tier Summary Table: This table summarizes detailed member data as of a User-defined date by User-defined family tier [e.g. Employee Only, Employee & Spouse, Employee & Child(ren), and Family].

 C. “UnderMod_Renew” – “UnderMod_Renew” uses historical summary information for membership, premium (if insured), claims, benefit plan, and other information (e.g. medical trend, claim incurral methodology, reinsurance stop loss, various expense parameters) to prepare an underwriting analysis (i.e. premium rate projection) for a large group that may contain multiple benefit plan options.


Please call Actuarial Modeling to discuss any of the above tools, or any of your other actuarial and financial modeling healthcare needs at (404) 531-0379.


You may also call Jim Galasso (see “Contact Information” above) for a document that summarizes the “Selected Features” for any of the above-noted tools.