Risk Adjustment & Coding

Risk adjustment moved further into an enforcement-and-operations phase this week, with MA plans and risk-bearing provider groups facing scaled CMS RADV scrutiny across all contracts while industry focus shifts from retrospective coding lifts to defensible documentation, ICD-10-CM specificity, and audit-ready chart evidence months before requests arrive. The emerging VBC tension is that accurate RAF capture remains central to MA, Medicaid managed care, ACA risk adjustment, and delegated-risk economics, but aggressive coding optimization—especially AI-enabled CDI and coding workflows—is increasingly being matched by payer and CMS audit analytics, raising compliance exposure for ACOs, enablement companies, and MA-aligned medical groups. See: RADV audit readiness and JAMA congressional view on MA risk adjustment reform.