Perspectives on risk adjustment, audit readiness, and value-based care for payers and providers.
OIG says CMS overpaid Medicare Advantage plans $462M on unsupported acute stroke codes. I tried to break the methodology the way a plan's lawyers would — here's why it holds, and the one habit underneath it.
With CMS's LEAD model arriving in 2028, organizations that treat data as an afterthought will face revenue volatility, benchmark surprises, and competitive disadvantage. Two priorities to fix it now.
CMS's 2027 Final Notice changes course on unlinked chart review for members changing plans, and lands a 2.48% pre-RA rate increase.
Most risk-bearing entities measure member engagement transactionally — cost per touch, response rate, short-cycle ROI. That math justifies doing less. Customer Lifetime Value flips it.
Every risk adjustment team in the country is staring at the same impossible list — 2025 retros, RADV prep, EDGE deadlines, 2027 bid development. The teams that stay ahead know which 20% drives 80% of results.
CMS just accelerated RADV audits to every eligible MA contract — annually. Coding staff ramped from 40 to 2,000. Plans and providers of all sizes are now in the crosshairs.
