The first full year of V28 is behind us. What did we actually learn?
When CMS introduced V28, many organizations approached it as a model update, something to adapt to, optimize around, and eventually stabilize. A year into operating under the new model, a different reality has emerged.
V28 was not just a recalibration. It was a signal. The stated intent from CMS was for V28 to create parity across Medicare VBC arrangements and at this stage of the game, it appears to have achieved its goal.
It signaled a shift toward tighter documentation standards, reduced tolerance for ambiguity, and a broader expectation that risk adjustment, quality, and care delivery operate from the same foundation of clinical truth. Moving forward, aside from accurate bids and managing MLR, Part C plans will need to push all three levers to be successful.
At RISE National, where Advantmed participated as a platinum sponsor, Matt Lambert joined Dr Chris Vojta to reflect on what this first year has revealed and where health plans need to go next.
From margin for error to margin for precision
One of the clearest changes under V28 is the disappearance of flexibility. With fewer HCCs and more stringent mappings, performance is no longer driven by volume. It is driven by accuracy.
Organizations that once relied on broad capture strategies are finding that approach increasingly ineffective. The plans maintaining performance are those that have invested in documentation integrity, aligning providers, strengthening clinical validation, and ensuring that every diagnosis is both supported and specific. No longer can a plan manage to the twenty percent of members who represent the most risk. Breadth of member engagement has become more important than depth. Risk, quality, and utilization management have become the three branches of VBC.
This is not a temporary adjustment. It is a new baseline.
The end of catch-up risk adjustment
Just as important is where and when risk is captured.
Historically, retrospective reviews played a central role in closing gaps and recovering value. Under V28 and emerging regulatory changes, that model is breaking down. The ability to catch up after the fact is diminishing, replaced by a need to get it right in the moment.
This shift is reinforced by early signals from the CY2027 Advance Notice. With only a 0.09 percent expected payment increase and an estimated 1.5 percent negative impact tied to excluding diagnoses from chart reviews not linked to encounters, the message is clear. Encounter based documentation is becoming the standard.
In this environment, performance is no longer recovered. It is created at the point of care.
Risk and quality are now one conversation
At the same time, the longstanding separation between risk adjustment and quality is fading. Both now depend on the same input, accurate, timely, clinically grounded data.
Incomplete documentation does not just affect RAF scores. It affects outcomes, measure performance, and gap closure. As a result, leading health plans are moving away from siloed operations and toward integrated models where risk, quality, and care management are aligned around a shared data strategy.
At RISE National, Dr. Matt Lambert put it simply
The goal of V28 was to create parity across CMS risk programs. That goal appears to have been achieved. Moving forward, it will behoove MAOs to adopt the most effective strategies from other Medicare VBC programs, focusing on risk, quality, and utilization with equal intention. –Dr. Matt Lambert, CMO & Head of Product Strategy, Advantmed
This convergence is accelerated by changes on the quality side as well.
The CMS CY2027 Medicare Advantage and Part D Proposed Rule signals a continued shift toward clinical relevance. Over the past several years, CMS has been simplifying the Star Ratings program, and that trend continues with the removal of measures like diabetic eye exams and statin use for cardiovascular disease. At the same time, new measures such as depression screening underscore a broader move toward whole-person, outcomes driven care.
Even more telling is what is not moving forward. The Excellent Health Outcomes for All measure will not be implemented, reinforcing that CMS is prioritizing measures that are both meaningful and operationally grounded.
Taken together, these changes point to a future where quality performance is less about administrative lift and more about what happens during care delivery.
A new level of scrutiny as RADV evolves
While payment and quality models are evolving, audit pressure is increasing in parallel.
RADV is becoming more targeted and more precise, with growing focus on high-risk codes, commonly miscoded conditions, acute diagnoses without sufficient support, and cancer related coding where specificity is critical.
At the same time, recent updates, including non-sequential audit years and newly announced audits for in-home assessments, highlight a broader expansion of audit scope.
This raises an important operational question for health plans. Is accuracy a technology problem or a training problem?
In reality, it is both. Technology can surface gaps and scale insight, but accuracy ultimately depends on what happens at the source, during the encounter, with the provider. Without alignment between the two, audit exposure increases.
What leading plans are doing differently
In response to these shifts, leading organizations are not making incremental adjustments. They are rethinking their operating models. If the advanced notice is adopted as is, plans will have to redesign their workflows at the point of care or with claims linkage.
Having spent much of my time in VBC creating point of care workflows, I know how effective they can be when payer and provider incentives are aligned. They can also become incredibly challenging and hard to scale, given competing priorities of health systems, IT departments, electronic health records, vendors, and health plans. Alternatively, some plans may find it more feasible to enhance the linkage between encounters and chronic conditions found on record reviews. Without getting too technical, this will require most plans to reconfigure the current state of their linking strategy. And given the variance between the date of the visit and when the encounter was signed, this strategy will require some sort of date range to find the correct encounter. Overfitting an algorithm always creates more problems than solutions and attempting to match exact dates will lead to more unlinked codes, not fewer.
Just as importantly, they are elevating the role of care management.
As financial pressure increases and documentation requirements tighten, performance is becoming more dependent on engaging members earlier, guiding them effectively, providing access at the most cost-effective area of care, and addressing chronic conditions before they escalate. In this new world, it may behoove plans to think of utilization management more as care management, which by any name is no longer a downstream function. It is becoming central to both risk and quality outcomes.
Looking ahead more change is coming
If the first year of V28 clarified anything, it is that this is not the final state.
Further changes to risk adjustment are likely, continuing the trend toward greater specificity, validation, and alignment with clinical reality. At the same time, the growing emphasis on care management and navigation suggests that performance will increasingly depend on how well plans connect data to action.
And with expanding audit activity, every part of the process from data capture to documentation to submission will face greater scrutiny.
The bottom line
V28 did not just change the math. It changed expectations.
Across risk adjustment, quality, and audit oversight, the direction is consistent. Performance will be defined by accuracy, clinical integrity, and execution at the point of care.
Health plans that continue to rely on retrospective, fragmented approaches will face increasing pressure. Those that invest in connected data, aligned teams, and real time workflows will be positioned not just to adapt, but to lead.