Risk Adjustment & Integrity

Risk adjustment integrity is moving from episodic enforcement to a standing operating constraint for Medicare Advantage and other risk-bearing models, with OIG audits of UnitedHealthcare’s MA diagnosis submissions and DOJ’s $22.5M Independence Blue Cross settlement reinforcing that unsupported coding can now create material repayment, False Claims Act, and reputational exposure for plans and delegated providers. At the same time, CMS is scaling RADV oversight across MA contracts while broader scrutiny—such as MedPAC’s defense of a $76B MA overpayment estimate—keeps pressure on Congress and the Trump administration’s CMS to tighten the link between documented disease burden, payment accuracy, and plan performance (DOJ settlement; RADV readiness). For ACOs, MA partners, and provider groups taking downside risk, the strategic shift is clear: revenue-cycle coding programs must be rebalanced toward prospective documentation quality, chart retrieval, encounter-data governance, and defensible clinical evidence—not just risk-score lift.