Risk Adjustment
Expert articles and analysis related to risk adjustment.
AI Summary — Last 30 Days
Risk adjustment is moving from a revenue-optimization lever to a core compliance and enterprise-risk issue for VBC organizations, as DOJ scrutiny of Medicare Advantage coding intensified with the $542M settlement involving Humana-owned The Villages Health over alleged manufactured diagnosis codes from 2020–2024 (Healthcare Dive). The case reinforces that MA-aligned physician groups, risk-bearing providers, and ACOs need tighter documentation governance, chart-review controls, and board-level oversight as CMS under the Trump administration continues to face pressure to improve the accuracy of MA risk adjustment and reduce coding-driven overpayments. Strategically, plans and provider groups should expect a more contested environment in which risk-score growth, Stars performance, and value-based contracting economics are increasingly constrained by audit exposure, RADV/False Claims Act risk, and policy attention to plan-level payment accuracy (MedPAC).
Related Articles
Accuracy of Medicare Advantage risk adjustment at the plan level - medpac.gov
Accuracy of Medicare Advantage risk adjustment at the plan level medpac.gov
The Villages Health System Agrees to $541.5M Settlement
Bankrupt Villages Health ordered to pay $541 million for bilking Medicare Advantage
Bankrupt Villages Health ordered to pay $541 million for bilking Medicare Advantage Villages-News.com
Humana-owned Villages Health agrees to $542M settlement for overbilling Medicare
Humana-owned Villages Health agrees to $542M settlement for overbilling Medicare Healthcare Dive
Humana-owned Villages Health agrees to $542M settlement for overbilling Medicare
The Central Florida provider manufactured fake diagnosis codes for its Medicare Advantage patients from 2020 to 2024, the DOJ said. Humana bought The Villages Health last year.
Compliance Program Lessons from the Complete Health Settlement
United States: Medicare Advantage Provider Monogram Health Agrees to Pay $2.4M to Settle False Claims Act Suit
United States: Medicare Advantage Provider Monogram Health Agrees to Pay $2.4M to Settle False Claims Act Suit The St Kitts Nevis Observer
For 4 Years, The Villages' Top Health Provider Allegedly Filed False Medicare Codes. The Bill Just Came Due: $541.5 Million. - 24/7 Wall St.
For 4 Years, The Villages' Top Health Provider Allegedly Filed False Medicare Codes. The Bill Just Came Due: $541.5 Million. 24/7 Wall St.
For 4 Years, The Villages' Top Health Provider Allegedly Filed False Medicare Codes. The Bill Just Came Due: $541.5 Million. - 24/7 Wall St.
For 4 Years, The Villages' Top Health Provider Allegedly Filed False Medicare Codes. The Bill Just Came Due: $541.5 Million. 24/7 Wall St.
Can AI in risk adjustment be trusted to code accurately?
Can AI in risk adjustment be trusted to code accurately? KevinMD.com