Medicare Advantage (MA) stands as a crucial component of the American healthcare landscape, offering private insurance alternatives to traditional FFS.
The Shift from Volume to Value
Traditional Fee-For-Service (FFS) models incentivize the volume of procedures. In contrast, Medicare Advantage emphasizes value, quality, and outcomes. The payment models rely heavily on accurate risk adjustment.
Capitation and Its Challenges
Under capitated models, plans receive a fixed amount per member per month (PMPM). If the clinical coding does not accurately reflect the patient disease burden, the plan takes on financial risk that is not offset by the payment.
EMEDLOGIX bridges this gap. By utilizing AI to sweep 100% of patient encounters, we ensure that the Risk Adjustment Factor (RAF) score is a true representation of the population health, protecting the financial viability of MA plans.