Risk Adjustment & Integrity

CMS under the Trump administration is tightening the economics of Medicare risk arrangements by revising LEAD Model methodology and proposing major CY 2027 MSSP financial changes, forcing ACOs to re-underwrite benchmarks, regional adjustment exposure, risk-track selection, beneficiary alignment, and TIN strategy ahead of PY 2027 (Wakely LEAD analysis; Wakely MSSP analysis). At the same time, integrity pressure is rising across the VBC stack: DOJ’s $14M Medicare Advantage upcoding settlement with Complete Health, new scrutiny of hospital-affiliated insurers’ ability to game payment rules, and insurer-level prior authorization transparency data all point to a policy environment where risk adjustment, coding discipline, and utilization management practices are becoming strategic—and compliance—determinants of margin. Mandatory bundled payment expansion through CJR-X further signals that CMS is pairing broader downside-risk participation with more aggressive guardrails against coding, benchmark, and utilization arbitrage.