Risk Adjustment & Coding

CMS and enforcement agencies are tightening the Medicare Advantage risk-adjustment environment, with HHS OIG audits of UnitedHealthcare and Humana plans alleging unsupported diagnosis submissions and DOJ securing a $22.5M False Claims Act settlement with Independence Blue Cross over inflated MA coding—signals that RADV exposure is becoming a core financial and compliance risk, not a periodic audit event (DOJ settlement; OIG MA audit). For ACOs, MA-aligned provider groups, and risk-bearing specialists, the strategic implication is a pivot from retrospective coding maximization toward prospective documentation integrity, chart-level audit readiness, and tighter payer-provider contract terms around encounter data, recoupments, and responsibility for unsupported HCCs. The broader tension is that policymakers and watchdogs are treating MA overpayment estimates—such as MedPAC’s $76B figure—as evidence for structural reform, while plans argue the risk-adjustment rules remain operationally ambiguous, creating uncertainty for VBC organizations whose margins depend on accurate acuity capture.