The transition from Risk Adjustment Model V24 to V28 isn't merely technical—it's transformative.
Starting with services delivered this year, the Centers for Medicare & Medicaid Services (CMS) will measure patient risk using only Model V28. The transition away from Model V24 to V28 has generated some concern among payers about its potential financial impact. CMS has projected that the new model could lead to an overall decrease in risk scores, which would result in overall lower reimbursement rates.
However, the transition to V28 doesn’t have to threaten health plan performance. Instead, successful health plans will see this as an opportunity to increase accuracy, accountability, and nuance. By using this risk adjustment measurement year as a catalyst to transform patient data and streamline workflows leveraging artificial intelligence (AI), health plans can experience the strategic shift they need to be highly competitive in the value-based care landscape.
Risk Adjustment Model V28: The strategic imperative for payers
Under Risk Adjustment Model V28, CMS aims to more accurately capture patient risk by better aligning the model with ICD-10-CM codes, expanding the number of Hierarchical Condition Categories (HCCs), and shifting the focus from the volume of diagnoses to their severity. Some diagnosis codes that were previously accepted are no longer recognized under the V28 model. As a result, capturing risk now requires greater clinical specificity to accurately reflect condition severity and ensure complex cases are fully accounted for.
The transition to V28 unlocks new opportunities for payers to make leaps when it comes to the comprehensiveness, accuracy, and depth of their risk adjustment data. Doing so will help ensure adaptability, compliance, and competitiveness under value-based care.
Success, delivered through data
Unfortunately, many health plans are failing to secure the breadth and depth of data they need to measure patient risk with extreme precision. Unlocking new data sources—from multiple health information exchanges (HIEs), lab results, and prescription information—can help plans uncover trends beyond the four walls of their networks. Payers must also capture everything possible within existing patient records by capturing and integrating both structured data and unstructured clinical notes.
By leveraging AI, increasing the breadth and depth of data can even uncover any missed or uncoded diagnoses. These insights empower plans to then target members with chronic or complex conditions to better align with CMS’s focus on severity over quantity of diagnoses. Finally, using AI-powered technology to deliver data and insights to clinicians at the point of care can improve documentation and better capture the true severity of member diagnoses.
Flexibility, efficiency, and scalability
Health plans can also use the transition to V28 as an opportunity to ensure highly accurate risk adjustment even as membership grows. Implementing cross-functional teams and agile infrastructure are critical steps to ensuring the flexibility and efficiency of workflows.
Additionally, incorporating AI-powered technology to increase the speed of risk adjustment-related tasks including medical record retrieval and clinical overview can drastically increase staff efficiency. A focus on flexibility and efficiency will help health plans scale without compromising data integrity, risking non-compliance, and watching reimbursements fall out of alignment with true patient risk.
Stronger provider relationships
Finally, the transition to V28 offers payers a valuable opportunity to strengthen relationships with providers by prioritizing clinical communication, shared education, and deeper collaboration. Working with providers to capture suspected diagnoses and close documentation gaps is perhaps the most critical step to more accurately capturing patient risk. Additionally, advanced reporting and analytics can offer clinicians timely data and performance insights, building a feedback loop with clinicians and ensuring adequate resources go to the highest-need populations.
A unified solution for evolving health care needs
Value-based care is entering a new era. With the upcoming CCMI deadline, the number of individuals enrolled in value-based care programs is expected to rise significantly by 2030. Meanwhile, payers and providers face increasing pressure to ensure reimbursement accuracy amid ongoing uncertainty, especially with the transition from HCC Model V24 to V28. Shifting patient expectations are also prompting providers to rethink their approaches.
Backed by 15 years of industry expertise, Reveleer has developed its risk adjustment solution to address both today’s and tomorrow’s most pressing value-based care challenges. Request a demo to learn more.
About the author
Sarah Fink is a seasoned product marketing leader with over 15 years of experience driving strategic growth in health are technology and digital health. As VP of Product Marketing at Reveleer, she leads initiatives to unify retrieval, clinical intelligence, risk adjustment, quality improvement, and member management solutions into a single, AI-powered platform for value-based care.