Governance · accountability
What no one owns
Governance is best read as an absence. Below is what the estate is missing: the metrics, domains and reports that have no named owner, and the accountability roles that exist on paper but sit empty. No person owns a single metric — that is the keystone finding.
52 of 106
metrics unowned
14 of 14
domains unowned
178 of 264
reports unowned
244 of 384
ownable nodes have no owner
Metrics
52 of 106 without an ownerMedical Loss Ratio (MLR)
Claims PMPM
Net Claims Cost
Days in Claims Payable (DCP)
Member Months
Active Membership
Total Premium Revenue
Risk Adjustment Factor (RAF)
Star Rating
COB Recovery Rate
Auto-Adjudication Rate
First-Pass Resolution Rate
Claims Denial Rate
Pended Claim Aging
Clean Claim Turnaround Time
Average Paid per Claim
Edit Override Rate
Provider Payment Accuracy
Capitation as % of Medical Spend
Retro Enrollment Rate
834 Auto-Adjudication Rate
Member Months Growth (YoY)
Dependent Coverage Ratio
Termination Rate (Annualized)
Eligibility Verification Match Rate
Accumulator Reconciliation Variance
Average Coverage Tenure (months)
Active Network Providers
Credentialing Cycle Time
Recredentialing Compliance Rate
Provider Directory Accuracy
Network Adequacy Pass Rate
Average Contracted Rate vs Medicare
Fee Schedule Load Completeness
PAR Provider Ratio
Provider Sanction Exposure
Authorization Turnaround Time (TAT)
Prior Auth Approval Rate
Pre-Service Denial Rate
Denial Overturn Rate
SLA Compliance Rate
Case Management Engagement Rate
30-Day Readmission Rate
Average Length of Stay (ALOS)
Care Plan Currency Rate
Rx PMPM
Generic Dispensing Rate (GDR)
Rebate Capture Rate
Prior Auth Approval Rate
Medication Adherence (PDC)
Specialty Spend Share
MAC Effectiveness (MAC %)
Premium AR Aging % > 90 days
Premium Collection Rate
Binder Payment Effectuation Rate
Days Sales Outstanding (Premium DSO)
Write-off Rate
Delinquency Rate
Unapplied Cash Ratio
Administrative Expense Ratio
Combined Ratio
IBNR Reserve Balance
Risk-Based Capital (RBC) Ratio
Days to Close
MLR Rebate Accrual
Unapplied Cash
IBNR Reserve Balance
Completion Factor
Reserve Redundancy/Deficiency
Loss Ratio Trend
Total Recoveries (FWA)
Identified Overpayment Dollars
Recovery Rate
Cost Avoidance / Savings
Aberrancy Hit Rate
Case Cycle Time
Net Promoter Score (NPS)
Member Persistency Rate
Lead Conversion Rate
Broker Commission Expense Ratio
Marketing Cost Per Acquisition (CPA)
Book-of-Business Retention Rate
Appeals Timeliness Rate
Grievance Timeliness Rate
Overturn Rate
Expedited Appeal Compliance Rate
Acknowledgement Letter Timeliness
Total Headcount
Full-Time Equivalent (FTE)
Voluntary Turnover Rate
Time to Fill
Total Labor Cost
Benefits Participation Rate
Overtime Hours Ratio
Mandatory Training Compliance
Average Base Salary
Offer Acceptance Rate
Pharmacy Net Cost PMPM
Provider Network Adequacy %
Appeal Overturn Rate
Fraud Recovery Rate
Underwriting Margin %
HEDIS Measure Rate
Open Gaps in Care
Medication Adherence (PDC ≥80%)
CAHPS Composite Score
Domains
14 of 14 without an ownerClaims
Finance
Provider
Clinical & Care
Membership
Workforce
Reporting & BI
Risk & Actuarial
Fraud
Appeals
Premium & Billing
Pharmacy
Sales & Broker
Quality & STARS
Reports
178 of 264 without an ownerDaily Adjudication Operations Dashboard
Pended & Aged Claims Inventory
Monthly MLR Pack (Claims Basis)
Net Claims Cost Reconciliation
COB Savings & Recovery Tracker
Claims PMPM Trend by Product Line
Denial Rate & Reason Analysis
Edit & Override Effectiveness
Prompt-Pay Compliance Report
Examiner Productivity Scorecard
Provider Payment Accuracy & Recovery
Capitation Settlement Report
High-Dollar Claim Review Log
Claims GL Reconciliation
IBNR & Claim Lag Triangle
Duplicate & Fraud Suspect Report
Encounter Submission Compliance
Executive Claims Cost Summary
Daily Active Membership Snapshot
Member Months Trend (Monthly)
Enrollment Operations Dashboard
834 Error Aging Report
Retro Enrollment Exception Log
Group Census & Enrollment by Employer
Premium Billing Reconciliation
CMS MMR Reconciliation Report
Medicaid Redetermination Worklist
Dependent Verification Audit
Termination & Reinstatement Summary
ID Card Fulfillment SLA
Accumulator Drift Audit
Eligibility Verification Volume (270/271)
Open Enrollment Election Tracker
Capitation Roster Drift Report
Membership Reconciliation Workbook (monthly close)
Coverage Tenure & Lapse Analysis
Network Composition Dashboard
Credentialing Pipeline Tracker
Recredentialing Due Report
Provider Directory Accuracy Scorecard
Network Adequacy Filing (CMS)
Fee Schedule Rate Analysis
Allowed Amount Pricing Audit
Contract Renewal Pipeline
Provider Roster Reconciliation
Sanction & Exclusion Monitoring
Value-Based Contract Performance
Provider Data Change Aging
PAR/Non-Par Status Reconciliation
Provider Quality Scorecard
Fee Schedule Load Exception Report
Provider Remittance Setup Audit
Daily UM Turnaround & SLA Dashboard
Prior Authorization Volume & Approval Trend
Denials & Overturn Analysis
Concurrent Review / Inpatient Census
30-Day Readmission Tracker
Case Management Productivity Report
Disease Management Program Outcomes
Care Plan Compliance & Overdue Review List
Regulatory UM Turnaround Compliance (CMS/State)
Gold-Carding Eligibility Review
HRA Completion & Outreach Status
Medication Reconciliation Post-Discharge
Reviewer Caseload & Capacity Planning
PHI Access Audit Report
Referral Leakage & Status Report
Auth-to-Claim Reconciliation
Care Gap & Suspect Condition Worklist
Monthly UM Executive Scorecard
Rx PMPM Trend by Line of Business
Monthly Rebate Accrual & Capture
Rebate Reconciliation Workbook
Pharmacy MLR Feed to Actuarial
Generic Dispensing & MAC Effectiveness
Prior Authorization Operations Dashboard
STAR Adherence (PDC) Gap Report
Specialty Drug Trend & Pipeline
DUR Alert & Override Audit
Opioid / Controlled Substance Surveillance
FWA Investigation Queue
CMS PDE Submission & Reject Tracking
Pharmacy Network Performance & DIR
Formulary Change Impact Analysis
Copay Accumulator & Maximizer Tracking
Top Drug Spend by GPI (Executive)
Pharmacy Claims Reject Analytics
Quarterly Pharmacy Audit Recovery
Monthly Premium Billed vs Collected
AR Aging Summary (Group & Individual)
Active Membership by Plan & Segment
Premium Revenue Recognition Roll-forward
Delinquency & Grace Period Watchlist
Binder Payment & Effectuation Tracker
Write-off & Bad Debt Reserve Analysis
Unapplied & Suspense Cash Report
Group Self-Bill Reconciliation Variance
CMS APTC/CSR Reconciliation Exception Report
Medicare Premium & SSA Withhold Reconciliation
Daily Cash Application Productivity
Collections Pipeline & Recovery
Termination-for-Nonpayment & Reinstatement Log
Broker Commission Accrual by Premium
Premium Tax & State Assessment Filing
GL Subledger Tie-Out (Billing to GL)
Invoice Dispute & Adjustment Trend
Board Financial Package - MLR & Underwriting
Monthly Close Financial Statements (P&L, Balance Sheet)
Trial Balance & Close Status Dashboard
NAIC Annual Statement (Blue Book)
ACA MLR Rebate Filing Worksheet
IBNR Reserve Roll-Forward
Premium Revenue Recognition & Membership Tie-Out
AP Aging & Cash Disbursement Forecast
Bank Reconciliation Exception Report
Budget vs Actual by Cost Center
Fixed Asset Depreciation Schedule
Capitation Expense by Provider
Income Tax Provision Pack
Intercompany Out-of-Balance Report
Suspense & Default-Mapping Exposure Report
Stale Accrual & Manual JE Audit
RBC & Solvency Trend
Reinsurance Recoverable Schedule
Monthly IBNR Reserve Certification Package
Completion Factor Triangle Workbook
Actuarial MLR Dashboard
Federal MLR Rebate Filing
RAF Yield & Gap Closure Report
CMS RAF Reconciliation Report
Reserve Development / Run-off Triangle
Pricing Trend & Assumption Summary
Underwriting Pipeline & Decision Log
Rate Filing Status Tracker
High-Cost Claimant & Stop-Loss Watchlist
Member Months & Exposure Reconciliation
Reserve Variance / Actual-to-Expected Analysis
Provider Risk Pool Settlement Report
Pharmacy Trend & Rebate Accrual Report
Experience Study Summary (Lapse/Morbidity)
Risk Adjustment Transfer Estimate (ACA)
Statement of Actuarial Opinion Workpapers
SIU Monthly Recovery & Savings Scorecard
Identified vs Recovered Funnel
Provider Aberrancy Top 200
Case Aging & SLA Breach Report
Net Claims Cost After FWA (Finance Reconciliation)
Investigator Productivity Dashboard
Pharmacy FWA / Opioid Surveillance
Prepayment Edit Effectiveness
Hotline & Referral Triage Log
Law Enforcement Referral Tracker
Sanction & Exclusion Screening Exceptions
Rule Hit & False-Positive Analysis
Vendor Recovery Performance
Chart Review Outcomes & Recoupable Dollars
Network Link Analysis Visualizer
Board Anti-Fraud Quarterly Summary
PHI Access Audit Report
Data Mining Yield Report
Broker Production Scorecard
Daily Sales Pipeline Dashboard
Commission Cycle Reconciliation
Sold Membership vs Enrollment Variance
NPS Trend & Verbatim Analysis
Campaign ROI & Attribution Report
Lead Source Performance Report
Retention & Churn Risk Report
Broker Commission Statement (broker-facing)
Agency Hierarchy & Override Report
Quote-to-Close Funnel
Group Renewal Pipeline
Broker Licensing & Appointment Compliance
Executive Sales & Distribution Review
Member CRM Engagement Report
Marketing Consent & Suppression Audit
Territory Coverage & Capacity Report
CMS Part C Reconsideration Universe (Table 1)
CMS Part D Coverage Determination & Appeals Universe
Daily Timeliness At-Risk Worklist
Overturn Root-Cause Analysis
Grievance Category Trend Dashboard
STARS Appeals Measure Pack (D-AM, C-AM)
Monthly Compliance Timeliness Scorecard
SLA Breach & Self-Disclosure Log
IRO / Level 2 Outcome Summary
ALJ & Higher-Level Appeals Tracker
Analyst Productivity & Queue Aging
CTM Complaint Reconciliation
State DOI Complaint Response Tracker
Quality-of-Care Referral Pipeline
Appeals Financial Impact (Overturn Recovery)
Expedited Appeals Real-Time Monitor
Reopening & Reconsideration Activity Report
A&G Volume per 1000 Members Trend
Monthly Headcount & Turnover Dashboard
Payroll Register
Labor Cost by Cost Center
Compensation Benchmarking Workbook
Annual Merit & Bonus Planning Model
Recruiting Funnel & Time-to-Fill
Open Requisitions Aging
Benefits Enrollment Summary
Open Enrollment Election Audit
Time & Attendance Exceptions
Overtime Trend Report
EEO-1 Component Report
Mandatory Training Compliance Scorecard
Performance Calibration Distribution
Succession & Talent Risk Heatmap
Contingent Workforce Spend
Leave & FMLA Tracking Report
Quarterly Workforce Analytics Pack
Board MLR Dashboard (monthly)
Executive KPI Scorecard
Membership Trend Report
Membership Reconciliation (Finance vs EDW)
Premium Revenue Recognition Report
Revenue Bridge (Billed-Collected-Earned)
Claims PMPM Trend
PMPM by Plan & LOB
MLR Regulatory Filing Workbook
Days in Claims Payable Tracker
Net Claims Cost Summary
Risk Adjustment RAF Dashboard
STARS Performance Dashboard
HEDIS Gap Closure Report
Pharmacy Spend & Rebate Report
Provider Network Adequacy Report
Provider Performance Scorecard
Appeals & Grievances Summary
SIU Fraud Recovery Report
Finance P&L by LOB
Utilization Management Dashboard
Inpatient & Readmission Report
Broker Commission Statement
Sales Pipeline Forecast
Quarterly Board Deck (KPI pack)
Statutory Reporting Pack
Membership Census by Geography
Revenue PMPM Cross-tab
Care Management ROI Report
Workforce Cost Allocation Report
Data Quality Exception Report
ETL Load Monitoring Dashboard
Trended MLR & Membership (ad hoc Excel)
Stars Executive Dashboard
Weekly Gap Closure Tracker
HEDIS Rate Trend Workbook
Star What-If Simulator
Medication Adherence PDC Report
CAHPS / HOS Survey Results
Provider Quality Scorecards (VBC)
IDSS Submission Package
Submission Validation Error Log
Chart Chase Inventory
Supplemental Data Yield Report
Denominator Reconciliation (Membership)
Health Equity Stratification Report
HEDIS Engine Run Audit Log
QRS Marketplace Rating Summary
Intervention Campaign ROI
Improvement Measure Movement
Provider Incentive Payout Reconciliation
Unfilled accountability
roles defined, no one holding them — and a process that does not existCanonical Medical Loss Ratio (MLR) definition owner
Accountability for one ratified "Medical Loss Ratio (MLR)" definition exists but no person holds it.
Canonical Claims PMPM definition owner
Accountability for one ratified "Claims PMPM" definition exists but no person holds it.
Canonical Net Claims Cost definition owner
Accountability for one ratified "Net Claims Cost" definition exists but no person holds it.
Canonical Days in Claims Payable (DCP) definition owner
Accountability for one ratified "Days in Claims Payable (DCP)" definition exists but no person holds it.
Canonical Member Months definition owner
Accountability for one ratified "Member Months" definition exists but no person holds it.
Canonical Active Membership definition owner
Accountability for one ratified "Active Membership" definition exists but no person holds it.
Canonical Total Premium Revenue definition owner
Accountability for one ratified "Total Premium Revenue" definition exists but no person holds it.
Canonical Risk Adjustment Factor (RAF) definition owner
Accountability for one ratified "Risk Adjustment Factor (RAF)" definition exists but no person holds it.
Canonical Star Rating definition owner
Accountability for one ratified "Star Rating" definition exists but no person holds it.
Canonical Medical Loss Ratio (MLR) definition & cadence (SOP)
No standing process defines "Medical Loss Ratio (MLR)" once and keeps it true.
Canonical Claims PMPM definition & cadence (SOP)
No standing process defines "Claims PMPM" once and keeps it true.
Canonical Net Claims Cost definition & cadence (SOP)
No standing process defines "Net Claims Cost" once and keeps it true.
Canonical Days in Claims Payable (DCP) definition & cadence (SOP)
No standing process defines "Days in Claims Payable (DCP)" once and keeps it true.
Canonical Member Months definition & cadence (SOP)
No standing process defines "Member Months" once and keeps it true.
Canonical Active Membership definition & cadence (SOP)
No standing process defines "Active Membership" once and keeps it true.
Canonical Total Premium Revenue definition & cadence (SOP)
No standing process defines "Total Premium Revenue" once and keeps it true.
Canonical Risk Adjustment Factor (RAF) definition & cadence (SOP)
No standing process defines "Risk Adjustment Factor (RAF)" once and keeps it true.
Canonical Star Rating definition & cadence (SOP)
No standing process defines "Star Rating" once and keeps it true.