Risk Adjustment & Benchmarking
Expert articles and analysis related to risk adjustment & benchmarking.
AI Summary — Last 30 Days
CMS is materially reshaping the ACO financial playbook for PY/CY 2027: the July 14 LEAD methodology update changes benchmarks, regional adjustment economics, beneficiary alignment, and TIN strategy, while the CY 2027 MSSP proposed rule would alter benchmark calculations and shared-savings forecasting in ways that could advantage some ACOs but pressure others depending on market position and risk track selection (Wakely on LEAD; Wakely on MSSP). At the same time, ACO REACH’s 2024 performance—$988 million in Medicare savings before its scheduled sunset—strengthens the case for high-risk accountable care, but recent DOJ upcoding allegations against Complete Health reinforce that risk adjustment integrity and coding governance are becoming central strategic risks for VBC organizations.
Related Articles
Complete Health to pay $14M to settle Medicare Advantage fraud allegations
The value-based primary care provider submitted false diagnosis codes to the CMS for three years, inflating its reimbursement by millions of dollars, according to the DOJ.
Research from University of Southern California Reveals New Findings on Dementia (Heterogeneous responses to risk-adjustment reform: evidence from dementia diagnosis in Medicare Advantage): Neurodegenerative Diseases and Conditions – Dementia
Research from University of Southern California Reveals New Findings on Dementia (Heterogeneous responses to risk-adjustment reform: evidence from dementia diagnosis in Medicare Advantage): Neurodegen...
Complete Health Partners Holdings $14M FCA Settlement: Medicare Advantage Risk-Adjustment Fraud
Complete Health Partners Holdings $14M FCA Settlement: Medicare Advantage Risk-Adjustment Fraud The National Law Review
Complete Health to pay $14.1M in Medicare Advantage coding misuse allegations settlement
Complete Health to pay $14.1M in Medicare Advantage coding misuse allegations settlement Fierce Healthcare
Florida MA provider pays $14.1M after allegedly pushing physicians to add unsupported diagnoses - beckersasc.com
Florida MA provider pays $14.1M after allegedly pushing physicians to add unsupported diagnoses beckersasc.com
Complete Health agrees $14.1 million False Claims Act settlement over Medicare Advantage coding
Complete Health agrees $14.1 million False Claims Act settlement over Medicare Advantage coding Traders Union
CMS Rewrites the LEAD Model Business Case: What ACOs Must Recalculate for PY 2027
How the July 14 Long-term Enhanced Accountable Care Organization (ACO) Design (LEAD) Model methodology update changes ACO benchmarks, risk-track decisions, beneficiary alignment, and Tax Identificatio...
A Technological Agenda For Risk-Adjustment Reform
A Technological Agenda For Risk-Adjustment Reform Health Affairs
The Trillion-Dollar Algorithm: Lessons From Machine Learning For MA Risk Adjustment
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Risk Adjustment Coding Deep Dive: Real‑World Insights from the Experts
Risk Adjustment Coding Deep Dive: Real‑World Insights from the Experts AAPC