Risk Adjustment & Benchmarking
Expert articles and analysis related to risk adjustment & benchmarking.
AI Summary — Last 30 Days
CMS is tightening the risk-adjustment and benchmarking environment on both sides of Medicare: the Trump administration’s 2027 Medicare Advantage rate notice includes a 2.48% payment increase while continuing pressure on MA coding intensity and unsupported diagnoses, reinforcing scrutiny of plan risk-score revenue as OIG flags potential overpayments tied to stroke coding. At the same time, CMMI’s new 10-year LEAD ACO model creates a major strategic decision point for ACOs—especially those weighing benchmark methodology, longitudinal risk capture, and downside-risk readiness ahead of the May 17, 2026 application deadline (Wakely on LEAD). For providers, conveners, and enablement companies, the through-line is clear: sustainable VBC performance will depend less on coding arbitrage and more on defensible HCC documentation, population-risk accuracy, and benchmark positioning as CMS narrows perceived MA advantages and tests new ACO designs (HFMA on MA payment policy).
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UnitedHealthcare sued for alleged $100M Medicaid fraud scheme
Massachusetts has sued UnitedHealthcare Insurance Company, alleging the insurer defrauded the state's Medicaid program of at least $100 million by making older members appear sicker or more impaired t...
To LEAD or Not: Accountable Care Organizations have a decision to make by May 17
LEAD (the Long-term Enhanced ACO Design) Model is the Centers for Medicare & Medicaid Innovation Center’s newest accountable care organization (ACO) payment model, running for 10 years from January 1,...
Payers did pretty well this quarter, but that trajectory could change
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From Premiums to Performance: Managing Risk in Self-Funded Health Plans
This brief is the second in a series outlining the fundamentals of self funding. It highlights key steps to successfully establish and manage a self funded health plan, with a focus on funding strateg...
CMS moves to curb MA plans’ unfair payment advantage
In April, CMS published its annual Medicare Advantage (MA) rate announcement for 2027.a For most years in recent memory, this would be a routine event, accompanied by no small amount of headshaking fr...
Cedar Gate Technologies Intensifies Payer Analytics and Medicare Advantage Focus Amid Rising Behavioral Health Risk
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