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Transitioning from retrospective to prospective risk adjustment: the time is now

Many health plans viewed prospective risk adjustment programs as nice to have but challenging to implement. But the CMS 2027 Advance Notice forces health plans to consider this model.

All insights

Blog

Transitioning from retrospective to prospective risk adjustment: the time is now

Historically, many health plans viewed prospective risk adjustment programs as nice to have but challenging to implement. Part of the challenge comes from the necessity to involve busy PCPs in a prospective solution. But the CMS 2027 Advance Notice forces health plans to consider this model.

Risk adjustment

Value-based care

Blog

The shift to digital quality: the new foundation for value-based care success

In 2025, Digital Quality Measures (DQMs) represents more than a technological upgrade — it’s a fundamental shift in how healthcare organizations define, measure and deliver quality.

Quality

Value-based care

Blog

Align risk adjustment strategy with provider support

Health plans can adapt to the changing landscape of risk adjustment by equipping primary care providers with the right resources. This approach was highlighted by Vatica Health in collaboration with Paul Shields, MD, chief medical officer and chief executive officer of Great Lakes Integrated Network IPA (GLIN IPA).

Health plan

Risk adjustment

Blog

Position your ACO for success with a focus on the basics

In ACO REACH and MSSP, coding and documentation are foundational to financial sustainability, compliance, quality performance and excellent care. Organizations that invest in robust documentation practices and risk-adjustment coding accuracy are better positioned to thrive in value-based care environments.

Provider

Value-based care

Blog

Unlocking the power of the Annual Wellness Visit

The AWV still hasn’t reached its full potential. In 2022 (the most recent dataset analyzed by CMS), 60% of all Medicare beneficiaries received an AWV. Among those with Original Medicare, the utilization rate was about 40%. This is an improvement from just 16% overall in 2011, but growth has plateaued, and uptake still lags far behind the benefit’s potential. When done right, the AWV doesn’t just check boxes — it can close critical care gaps, strengthen patient relationships, improve quality scores and lower long-term costs.

Annual wellness visit

Provider

Blog

How to boost your MA-PD Star scores through accurate risk adjustment

Accurate risk adjustment is foundational to ensuring that Star ratings reflect true quality, rather than differences in member health. Accuracy ensures CMS appropriately compensates plans for managing complex populations, rewarding those that deliver superior care despite higher patient acuity.

Quality

Risk adjustment

Blog

Health plans and providers join forces to navigate turbulent market conditions

Multiple headwinds have created a challenging Medicare Advantage market for both health plans and providers. These headwinds include the transition to CMS-HCC V28 for risk adjustment, heightened regulatory scrutiny, increased audit activity, reimbursement pressure, shifting star ratings and evolving expectations under new CMS leadership. Presenters at the 2025 RISE National conference suggested a unique way to address the situation: shared resources among health plans and providers to maximize compliant risk adjustment performance.

Health plan

Provider

Risk adjustment

Blog

Technology in risk adjustment: opportunities and pitfalls

One area seeing a surge in AI-driven innovation is HCC coding and documentation. A growing number of tools now aim to automate risk adjustment coding, promising increased efficiency and reduced costs. While these solutions offer potential benefits, they also present serious challenges that health plans and providers must carefully evaluate.

Risk adjustment

Value-based care

Blog

What’s going on with Medicare Advantage and risk adjustment?

One of the biggest challenges facing MA plans concerns changes to risk adjustment regulations. These changes in turn affect providers. Risk adjustment is complex, and most providers are not well versed on this topic. Let’s break it down and explore how the right partnerships and resources can help providers succeed in the current turbulence that’s affecting the MA ecosystem.

Risk adjustment

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