RISE West 2026 opened Sept. 3 in San Diego with co-chairs Ana Handshuh, principal at CAT5 Strategies, and Melissa Newton Smith, founder and senior advisor at Newton Smith Group, prepping the audience to get ready for a regulatory heavy morning.
The opening panel included Neil Patil, senior fellow and policy director of the Medicare Policy Initiative at Georgetown’s Center on Health Insurance Reforms, Julie Brown-Georgi, founder and CEO of Digital Health Policy Strategies, and Mark Newsom, president and founder of Health Evaluations, LLC.
Their assignment was the policy shifts for 2026 and 2027 carrying direct bottom-line impact.
The frame: CMS moves in increments, CMMI moves by waiver
The panel opened with a distinction worth carrying into any policy conversation. Outside the CMS Innovation Center and its waiver authority to pilot structural change, CMS builds policy incrementally rather than in one leap. The big swings come through the Innovation Center. Everything else arrives through advance notices, rate announcements, and rulemaking, one increment at a time.
Prior authorization is turning into an engineering project
Brown-Georgi walked the room through the target state for prior authorization, and it bears little resemblance to how the work happens today. Today means fax, portals varying payer by payer, and clinical systems with no shared workflow. The target state moves the whole exchange into a real-time sequence running inside the provider’s own system, and she stepped through that sequence in detail.
The date behind it is the one attendees already knew and heard again anyway. The federal API requirements land in January, and the room did the math on how few months that leaves.
The bills and the one new law
Newsom and Patil ran the Capitol Hill picture. Four items came up by name.
Improving Seniors’ Timely Access to Care Act. Prior authorization transparency reporting, headed to CMS rather than to corporate websites. Both relevant House committees moved it over the summer, and a floor vote is possible this fall.
No UPCODE Act. The bipartisan Senate bill aimed at the sources of risk adjustment diagnoses, in play for several years now.
REAL Health Providers Act. Enacted this year, with hard new requirements for Medicare Advantage (MA) provider directories and a compliance date the panel walked through. A proposed rule with enforcement detail is expected this fall.
The transparency package. Several bills would expand reporting on medical loss ratios, on the cost and use of supplemental benefits down to the enrollee level, and on encounter data.
The panel put each one on a rough timeline and explained where the reporting burden would land inside a plan. That part was the reason people stayed in their seats.
Risk adjustment: one question settled, the next one open
CMS has already finalized its treatment of chart review records without an associated encounter, effective with the 2027 payment year, and the panel unpacked what CMS changed between the proposal and the final policy. Some organizations feel that change more than others, and the panel was specific about which ones.
The open question is what comes next. Newsom traced the arc from a 2021 federal report through congressional investigations and MedPAC recommendations, then described the debate inside the agency between adjusting the sources of diagnoses and rebuilding the models and rates outright. He named where he expects attention to turn, and named the vehicle it would travel in.
What the appointees are signaling
Public statements from senior political appointees drew close reading from the panel, including a memorable line from the CMS administrator on supplemental benefits spending. The message underneath it was clear enough. Taxpayer-funded MA benefits should point at clinical care, quality improvement, Star Ratings, and population health rather than perks.
CMS quality leadership carried a parallel message on outreach. Deliver to 100 percent of your enrollees. The panel spelled out which common practices that directive puts under a brighter light.
The cost nobody puts on a slide
Brown-Georgi named something the policy conversation usually skips. The health tech ecosystem has traveled from regional exchanges to the current national framework in about 15 years, with major federal action along the way, and each shift resets the build.
Plans and providers now struggle to justify the next capital request for the next API while the guidance keeps moving. Her case for pressing forward anyway came down to structure. Standardized data and transport take administrative friction out of the system permanently. She described the split inside many organizations in a way that landed with the room: high-end clinical artificial intelligence running alongside spreadsheets and telephones.
Newsom’s charge
The most direct moment of the morning was an appeal.
“Everybody should be involved in this. It’s your business. You’re not just regulated by the government, you’re paid by the government.”
Trade organizations do important work, he said, and local organizations understand their own markets and beneficiaries better than any national group. Members of Congress prefer hearing from organizations inside their own footprint.
He also pointed to two research shops with real influence on Capitol Hill and at CMS, the Duke-Margolis Institute for Health Policy and West Health, and explained how their work on risk adjustment and quality models tends to show up later in federal policy.
RISE takes the risk adjustment side of these changes further at the 27th Risk Adjustment Forum, October 27-29, in Orlando, with RADV defense, a live audit simulation, documentation integrity, and AI governance in coding operations on the agenda.