Risk Adjustment & Coding
Expert articles and analysis related to risk adjustment & coding.
AI Summary — Last 30 Days
Risk adjustment enforcement is moving from episodic compliance risk to a core strategic constraint for VBC organizations, as DOJ actions against MA-linked providers—including Complete Health’s $14M settlement for allegedly false diagnosis submissions and The Villages Health’s $541M+ settlement over alleged fabricated MA codes—signal heightened scrutiny of coding-driven revenue models in delegated-risk, primary care, and payer-owned assets. For ACOs, MA groups, and population health platforms, the near-term implication is a shift from growth-through-capture to defensible documentation, clinical validation, and audit-ready governance—especially as CMS under the Trump administration continues to pressure payment integrity while expanding mandatory model activity such as the forthcoming nationwide joint replacement model. See coverage of Complete Health’s settlement and The Villages Health settlement.
Related Articles
The Villages Health System Agrees to $541.5M Settlement
Bankrupt Villages Health ordered to pay $541 million for bilking Medicare Advantage
Bankrupt Villages Health ordered to pay $541 million for bilking Medicare Advantage Villages-News.com
Humana-owned Villages Health agrees to $542M settlement for overbilling Medicare
Humana-owned Villages Health agrees to $542M settlement for overbilling Medicare Healthcare Dive
Humana-owned Villages Health agrees to $542M settlement for overbilling Medicare
The Central Florida provider manufactured fake diagnosis codes for its Medicare Advantage patients from 2020 to 2024, the DOJ said. Humana bought The Villages Health last year.
Compliance Program Lessons from the Complete Health Settlement
United States: Medicare Advantage Provider Monogram Health Agrees to Pay $2.4M to Settle False Claims Act Suit
United States: Medicare Advantage Provider Monogram Health Agrees to Pay $2.4M to Settle False Claims Act Suit The St Kitts Nevis Observer
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.
How AI and Analytics Can Support More Proactive Risk Adjustment
How AI and Analytics Can Support More Proactive Risk Adjustment Optum Business
The Villages Health Fined $541.5M for Fake Diagnosis Codes on Seniors
The Villages Health Fined $541.5M for Fake Diagnosis Codes on Seniors Hoodline
ACA Supplemental Claims Are Reshaping Risk Adjustment Strategy
Supplemental claims have become a critical driver of ACA risk adjustment accuracy, financial performance, and RADV preparedness for health plans. According to Wakely’s 2025 ACA Supplemental Claims Imp...