Risk Adjustment is fundamentally an exercise in data management. We generate data through clinical assessments, we manage data through the submissions process, and we reconcile our data with CMS.
With CMS’s LEAD model coming in 2028, CMS is doubling down on data. Organizations that treat data as an afterthought will face revenue volatility, benchmark surprises, and competitive disadvantage.
To be truly ready by 2028, payers and providers must act now on two critical fronts:
1. Collaborate on complete, accurate two-way data flows.
Plans and providers need seamless, bidirectional exchange — not one-way claims submission. Every encounter, Rx fill, and utilization signal must flow cleanly in both directions.
2. Master internal data stewardship.
You must be able to:
- Account for every single piece of data that comes in your door
- Proactively identify data that should have arrived but didn’t
- Track and reconcile every record until it is fully validated and matched with CMS
In short: treat your data infrastructure with the same rigor you apply to financial reconciliation. In the AI era, incomplete or unreconciled data equals inaccurate risk scores equals lost revenue.
The organizations that start building this discipline today will enter 2028 with confidence, stability, and a real edge.
If you lead a health plan, ACO, or provider group and want to turn this regulatory shift into a strategic advantage, Bigelow Healthcare Consulting specializes in exactly these readiness programs — data-flow mapping, stewardship frameworks, reconciliation playbooks, and AI-impact modeling. Let’s talk.
If you’re building the data discipline your program will need before the LEAD model arrives in 2028, we can help you map your two-way data flows, stand up stewardship, and pressure-test reconciliation against CMS.
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