incurred but not reported claims

This Subtopic governs recognition and disclosure of liabilities unique to health care entities, principally accrued health care costs under capitation and other risk-bearing payor contracts. Providers that bear risk for referrals and outside services must accrue a liability for unpaid claims, including incurred but not reported (IBNR) claims, and must accrue health care costs as services are rendered, including services required beyond the premium period and post-termination costs. It also clarifies that entering into a Medicare fraud settlement that requires five years of future compliance audits is not itself the obligating event, so no liability is recognized for those future audits.

This subtopic applies Topic 450 loss-contingency principles to health care entities, principally medical malpractice claims, prepaid health care contract losses, and preferred provider "stop-loss" guarantees. Malpractice liabilities must be accrued when the incidents giving rise to the claims occur — including losses from incidents probable of having occurred but not yet reported — based on best estimates of ultimate claim costs, and may not be presented net of anticipated insurance recoveries. Losses on prepaid health care contracts are recognized when it is probable that expected future health care and maintenance costs on a group of existing contracts will exceed anticipated future premiums and stop-loss recoveries.

ASC 720-954 governs how health care entities account for insurance-related and other operating expenses, principally retrospectively rated insurance policies, claims-made policies, malpractice loss accruals, multiprovider captive insurance arrangements, and stop-loss insurance. The core rules turn on whose loss experience drives the premium: if the entity's own experience, the minimum premium is expensed over the coverage period and recoveries are deferred until estimated losses exceed the stipulated maximum premium; if a group's experience, additional premiums or refunds are accrued based on group experience to date, including asserted and unasserted, reported and unreported claims.

ASC 944-40 governs how insurance entities recognize and measure claim costs and liabilities for future policy benefits, with separate subsections for short-duration contracts, long-duration contracts, reinsurance contracts, and financial guarantee insurance contracts. Its core rules are that liabilities for unpaid claims (including IBNR) and claim adjustment expenses are accrued when insured events occur, and that a liability for future policy benefits—the present value of future benefits and related expenses less the present value of future net premiums—is accrued when premium revenue is recognized. Post-ASU 2018-12, cash flow assumptions are updated at least annually with remeasurement gains/losses in net income, the discount rate is an upper-medium grade (low-credit-risk) fixed-income yield updated each reporting date through OCI, and market risk benefits are measured at fair value.

ASC 965-30 governs how a health and welfare benefit plan measures and reports its own benefit obligations (as distinct from the sponsoring employer's obligations). Benefit obligations, measured at actuarial present value as of the plan's year end, comprise three classifications: (1) claims payable, claims incurred but not reported (IBNR), and premiums due to insurance entities; (2) accumulated eligibility credits and postemployment benefits; and (3) postretirement benefits split among retirees, participants fully eligible, and participants not yet fully eligible (965-30-35-1). Plans must also present the significant factors causing year-to-year changes in each classification.