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Health assessments are often the first meaningful connection between health plans and their members. They provide a unique opportunity to identify risk factors, document chronic conditions, and uncover social determinants of health (SDOH) that impact access to care. But while they are a critical first step, health assessments are only the beginning of enabling ongoing,… Continue reading Why Continuity of Care After Health Assessments is Critical for Health Plan Success
Risk Adjustment Data Validation (RADV) audits are now an annual reality for every Medicare Advantage (MA) contract. In what’s widely seen as the most significant shift in risk adjustment oversight in more than a decade, CMS is moving quickly to clear a seven-year audit backlog and begin auditing all eligible contracts for each payment year.… Continue reading RADV Audits: What Medicare Advantage Plans Need to Know
On April 7, the Centers for Medicare & Medicaid Services (CMS) released the final 2026 Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies. This notice confirms key updates to risk adjustment, plan payments, and program requirements, solidifying several proposals from the earlier CMS Advance Notice. Here’s what health plans need… Continue reading 2026 CMS Final Notice: Everything Plans Need to Know
On January 10, CMS released the 2026 Advance Notice for Medicare Advantage (MA) plans, detailing proposed changes to MA capitation rates and Part C and Part D payment policies. This notice brings significant updates, including the full implementation of the V28 risk adjustment model for CY 2026, projected payment adjustments, and shifts in Part D… Continue reading 2026 CMS Advance Notice: Impacts on Medicare Advantage
As we approach the upcoming Affordable Care Act (ACA) Open Enrollment period starting November 1, it’s crucial for health plans to prepare for what could be another record-setting year. Last year’s open enrollment saw a historic 21.3 million people sign up for ACA Marketplace coverage—marking a 30% increase from the previous year and setting a… Continue reading ACA Risk Adjustment: 3 Keys to Open Enrollment Success
Today’s healthcare landscape is constantly evolving and with new regulations impacting risk adjustment, health plans are reevaluating their retrospective coding projects. With advances in analytics, technology, and Artificial Intelligence (AI), health plans have an opportunity to make their risk adjustment programs more efficient than ever before by implementing complete code capture. Complete code capture is… Continue reading 3 Reasons Why Your Health Plan Should Implement Complete Code Capture for Risk Adjustment
Health plans are facing a storm of changes with the arrival of the V28 risk adjustment model for Medicare Advantage, along with increased scrutiny from the OIG and CMS. With audits on the rise and regulations constantly shifting, plans need different strategies and approaches to ensure their risk adjustment and quality programs are compliant. We… Continue reading Navigating V28 and the Changing Regulatory Landscape: 3 Strategies for Health Plans
On April 1, The Centers for Medicare & Medicaid Services (CMS) released the Medicare Advantage (MA) PY2025 Final Notice. Here are some of the highlights for risk adjustment and quality programs: Risk Adjustment Model Updates Most commentators supported the continued rollout of the V28 risk model. The main improvements to the V28 risk model are the… Continue reading CMS PY2025 Final Notice: A Summary
On January 31, The Centers for Medicare & Medicaid Services (CMS) released the Medicare Advantage (MA) PY2025 Advanced Notice. Some of the highlights include: Rollout of V28 Risk Adjustment Model Based on analysis of the impacts of the risk adjustment model, CMS has concluded that it is necessary and appropriate to continue the phase-in of… Continue reading CMS PY2025 Advance Notice: A Clinical Perspective
Medicare Advantage (MA) organizations are under extreme scrutiny to ensure proper coding to reduce overpayments for MA beneficiaries. The recent toolkit released by the Office of Inspector General (OIG) identifies the commonly miscoded diagnosis codes that result in inaccurate risk adjustment scores and lead to overpayments. OIG found that over 70% of the codes were… Continue reading Risk Adjustment Coding Challenges: Reducing MA Audit Risk
