Designing an API-First Value-Based Care Analytics Stack for MA Payers

Short summary

Medicare Advantage payers need deterministic, auditable analytics for Risk Adjustment Factor (RAF) scoring—the algorithmic basis of plan payment. Treat this as an engineering problem: enforce strict encounter schemas at ingestion, build idempotent APIs with explicit model versioning, track evidence (labs, meds, prior diagnoses) for defensibility, and delegate hierarchy logic to external scoring services. The payoff: reproducible scores, audit readiness, and RADV exposure modeling before CMS conducts audits.

• •Enforce strict encounter schemas and reject malformed data—loose ingestion is the #1 source of bad RAF analytics
• •Build idempotent scoring APIs with explicit model versioning; store the model string with every result for auditability
• •Attach evidence (labs, meds, prior diagnoses) to suspicious diagnoses; expose RADV sampling and extrapolation as an API before CMS audits

Generated with AI, which can make mistakes.