Risk Adjustment & Benchmarking
Expert articles and analysis related to risk adjustment & benchmarking.
AI Summary — Last 7 Days
CMS and oversight bodies are tightening scrutiny on risk adjustment across Medicare Advantage, Medicaid managed care, and Marketplace programs, with the Trump administration’s 2027 MA rate direction and recent OIG findings on unsupported stroke diagnoses reinforcing pressure on plans’ coding-driven revenue strategies and narrowing the perceived payment advantage over traditional Medicare (HFMA). At the same time, Massachusetts’ lawsuit alleging UnitedHealthcare inflated acuity in MassHealth senior plans underscores that upcoding risk is no longer just an MA issue, raising compliance stakes for Medicaid MCOs, vendors, and provider partners using prospective AI-enabled documentation tools. For ACOs and VBC organizations, the parallel debate over LEAD and geographically dispersed, convener-led Medicare ACOs is sharpening the policy tension between rewarding legitimate population-health performance and preventing benchmarking/risk-score arbitrage that can generate high savings without commensurate care transformation ([Health Affairs](https://news.google.com/rss/articles/CBMi7AFBVV95cUxQZzBkcEZQTjlhUkF3ZjRTOUFtaGljNi1ncHVzMFQ3Y3BjM3NvYzFOQURIS0p6ZnhmRWRPYjEzRHhjU3U4eExUQ0pIRERaQWo1N2tHdXlkNX
Related Articles
Developing a Primary Care-Specific Risk Adjustment Model: Lessons from MassHealth
Developing a Primary Care-Specific Risk Adjustment Model: Lessons from MassHealth  Center for Health Care Strategies
HHS Finalizes Sweeping Marketplace Changes (Part 4): Standardized Plans, Risk Adjustment, And More
HHS Finalizes Sweeping Marketplace Changes (Part 4): Standardized Plans, Risk Adjustment, And More  Health Affairs
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...
Massachusetts sues UnitedHealthcare for alleged Medicaid fraud
The state claims UnitedHealthcare inflated the sickness of seniors enrolled in MassHealth managed care plans to reap at least $100 million in improper payments.
The LEAD model explained: A deep dive into the new ACO design
The LEAD model explained: A deep dive into the new ACO design  Aledade
OIG: Feds may have overpaid MA plans by millions due to unsupported stroke diagnoses
OIG: Feds may have overpaid MA plans by millions due to unsupported stroke diagnoses  Fierce Healthcare
Third-Party Convener Firms And The Rise Of Geographically Dispersed, High-Earning Medicare ACOs
Third-Party Convener Firms And The Rise Of Geographically Dispersed, High-Earning Medicare ACOs  Health Affairs
What is risk stratification in healthcare?
What is risk stratification in healthcare?  Aledade
STAT+: Massachusetts sues UnitedHealth, alleging fraud in state’s Medicaid plans for seniors
State AG alleges UnitedHealthcare claimed some members were sicker to boost its profits.
Navina Steps Up Prospective AI Risk Adjustment Push Amid Regulatory Shift
Navina Steps Up Prospective AI Risk Adjustment Push Amid Regulatory Shift  TipRanks