Risk Adjustment & Coding
Expert articles and analysis related to risk adjustment & coding.
AI Summary — Last 7 Days
Risk adjustment scrutiny intensified across MA, Medicaid managed care, and ACA marketplaces, with CMS moving to narrow Medicare Advantage coding/payment advantages while OIG findings suggest MA plans may have received up to $462M tied to unsupported acute stroke diagnoses—raising the compliance stakes for plans, delegated provider groups, and VBC entities reliant on diagnosis capture. At the same time, Massachusetts’ suit alleging UnitedHealthcare inflated acuity in MassHealth senior managed care plans shows Medicaid risk adjustment is facing similar enforcement pressure, even as primary-care-specific models and prospective AI coding tools gain traction amid tighter oversight. For ACOs and population health organizations, the signal is clear: accurate documentation and clinically supported risk stratification are becoming strategic assets, not just revenue-cycle functions, as regulators challenge coding intensity across programs (HFMA on MA payment advantage; Massachusetts Medicaid fraud suit).
Related Articles
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
Navina Steps Up Prospective AI Risk Adjustment Push Amid Regulatory Shift
Navina Steps Up Prospective AI Risk Adjustment Push Amid Regulatory Shift  TipRanks
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
CMS may have overpaid MA plans $462M for unsupported acute stroke diagnoses
CMS may have overpaid MA plans $462M for unsupported acute stroke diagnoses  Becker's Payer Issues
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.
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.
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
I Am AAPC: Chimeka Kindred, MBA, CPC, CRC, CPMA, AAPC Approved Instructor
Diagnostic coding misses more than half of long COVID cases: Study
Diagnostic coding misses more than half of long COVID cases: Study  Becker's Hospital Review