Risk Adjustment & Coding
Expert articles and analysis related to risk adjustment & coding.
AI Summary — Last 30 Days
Risk adjustment is moving from a revenue-optimization function to an enterprise compliance and VBC contracting risk, as CMS and enforcement agencies intensify scrutiny of Medicare Advantage diagnosis submissions through scaled RADV activity, OIG audits, and False Claims Act settlements. The latest signal is Independence Blue Cross’s $22.5 million settlement over allegedly unsupported MA diagnoses, alongside OIG’s audit of UnitedHealthcare Benefits of Texas, reinforcing that payers and risk-bearing providers need stronger prospective documentation controls, chart validation, and delegation oversight before codes flow into payment.
Strategically, the debate is shifting from isolated coding errors to whether MA’s risk-adjustment architecture structurally overpays plans, with MedPAC defending a $76 billion overpayment estimate while plans press Congress to revise the methodology—an issue that could affect MA benchmarks, shared-savings economics, provider capitation rates, and the ROI of population health investments tied to coded acuity.
Related Articles
RADV Audits: What payers and risk-bearing providers need to know | Charta Health
From newsletter: CMS reverses some of its 760,000 ACA cancellations | Cigna sued over ground ambulance payments | ACA subsidy verification rule proposed | 8 notes on MA star ratings | 31 payer exe...
Office of Public Affairs | Independence Blue Cross to Pay $22.5M to Resolve False Claims Act Allegations - Department of Justice (.gov)
Office of Public Affairs | Independence Blue Cross to Pay $22.5M to Resolve False Claims Act Allegations Department of Justice (.gov)
Medicare Advantage Compliance Audit of Specific Diagnosis Codes That UnitedHealthcare Benefits of Texas, Inc. (Contract H0609), Submitted to CMS - Office of Inspector General (.gov)
Medicare Advantage Compliance Audit of Specific Diagnosis Codes That UnitedHealthcare Benefits of Texas, Inc. (Contract H0609), Submitted to CMS Office of Inspector General (.gov)
Assigned code vs. Note documentation
Assigned code vs. Note documentation AAPC
Reforming Risk Adjustment in Medicare Advantage—A View From Congress
Reforming Risk Adjustment in Medicare Advantage—A View From Congress JAMA
How Medical Coding Services Help Medicare Advantage Plans Get Risk Adjustment Right
How Medical Coding Services Help Medicare Advantage Plans Get Risk Adjustment Right The Good Men Project
AI in risk adjustment: The shift from point solutions to operational efficiency
AI in risk adjustment: The shift from point solutions to operational efficiency Becker's Hospital Review
Audit Readiness is Decided Months Before the First Chart Request Arrives
The following is a guest article by Michael Egbert, Chief Executive Officer at Sherpas Healthcare Solutions CMS has scaled Risk Adjustment Data Validation (RADV) to a degree the industry has never see...
ACA RADV Is More Than a Compliance Requirement
How ACA Risk Adjustment Data Validation can affect financial results, operational strategy, and long-term risk adjustment performance ACA Risk Adjustment Data Validation (RADV) is not simply a regulat...
Duke-Margolis Has Vision for Modernizing MA Risk Adjustment
Duke-Margolis Has Vision for Modernizing MA Risk Adjustment HCI Innovation Group