Cut through the noise, find the signal: Intelligence for serious healthcare leaders
How Medicare Advantage, ACOs and ACA plans get paid for how sick their members are — and where the scrutiny is heading.
How exposed is your plan to the proposed 2027 exclusion of unlinked chart review records?
What percentage of your current risk score comes from diagnoses captured only through retrospective chart reviews not tied to encounters?
What is your plan’s estimated RAF compression under full V28?
Have you modeled the financial impact of conditions that no longer map to HCCs or carry reduced weights?
Is your RADV audit readiness sufficient for CMS’s expanded audit program?
With CMS now targeting all 550 eligible contracts and reviewing up to 200 records per plan, can your organization respond to multiple concurrent audit years (PY2018–2024)?
How dependent is your risk adjustment strategy on health risk assessments (HRAs) vs. provider encounter-based documentation?
The OIG has specifically flagged HRA-only diagnoses as a compliance risk.
What is your coding intensity profile relative to FFS benchmarks?
MedPAC estimates the industry average is approximately 10.8% above FFS — where does your plan fall, and what is defensible vs. vulnerable?
Are you prepared for the possible shift to two-year diagnostic data windows?
MedPAC and others have recommended this change, which would fundamentally alter annual recapture strategies.
How will you maintain supplemental benefits and premium stability if 2027 rates come in near the proposed 0.09% base increase?
How accurately does your HHS-HCC coding reflect the true acuity of your enrolled population?
Unlike MA where plans proactively code, many ACA issuers underinvest in risk adjustment optimization.
Are you net payers or net receivers in the ACA risk transfer settlement?
If you are consistently paying into the risk transfer pool, are your premiums appropriately reflecting your lower-acuity population?
How are you managing the pediatric and maternity HHS-HCC categories that have no equivalent in CMS-HCC?
These are significant cost drivers in the ACA population.
What is the financial impact of members churning between Medicaid and ACA coverage on your risk scores?
Partial-year enrollment creates significant risk adjustment challenges.
Are you using your risk adjustment data to identify high-risk members for care management, or only for financial purposes?
The HHS-HCC concurrent model provides real-time signals about member acuity.
Do you understand how CMS-HCC risk scores affect your ACO’s benchmark?
In MSSP, the benchmark is risk-adjusted, meaning that rising risk scores in your attributed population can increase your benchmark, but CMS now caps risk score growth at 3%.
Are your participating providers documenting conditions with the same rigor as MA plan providers?
MSSP ACOs often leave significant risk score value undocumented because FFS providers lack the coding infrastructure and incentives that MA plans deploy.
For ACO REACH participants: do you understand the difference between the CMS-HCC prospective model and the CMMI-HCC concurrent model?
The concurrent model captures real-time acuity but is more volatile.
How will the transition from ACO REACH to MSSP or the new LEAD Model affect your risk adjustment strategy?
LEAD introduces reformulated benchmarks and new risk arrangements beginning 2027.
Are you modeling the impact of CMS’s 3% cap on risk score growth from 2019 to 2026?
This can significantly reduce benchmark favorability for ACOs that had substantial risk score growth.
Which risk adjustment model has the largest financial exposure for your organization?
If you operate both MA contracts and MSSP ACOs while also participating in ACA markets, you are exposed to three different risk adjustment regimes simultaneously.
Is your clinical documentation improvement (CDI) program calibrated for V28 specificity requirements, or still optimized for V24?
Many CDI programs need recalibration.
What is the revenue-at-risk from RADV clawbacks across your MA contracts?
A single audit finding extrapolated across your contract population could represent tens of millions of dollars.
Are you investing in NLP and AI-assisted coding tools to improve documentation accuracy at the point of care?
Organizations using these tools are reporting significantly higher coding accuracy and audit success rates.
How are you balancing the push for higher risk scores with the growing regulatory scrutiny of upcoding?
The line between thorough documentation and inappropriate coding is being drawn more sharply with each passing year.