Wednesday afternoon at The 27th Risk Adjustment Forum in Orlando covered CDI, AI, audit operations, RADV, ACA risk adjustment and plan finance, and speakers kept coming back to one shift. Risk adjustment teams are moving from fixing errors after submission to getting documentation right at the source, because audits are coming either way.
Here are five takeaways for risk adjustment, coding, CDI and compliance leaders at Medicare Advantage and ACA plans.
1. Prospective and retrospective review belong in one loop
Panelists on the prospective CDI panel and the “Strengthening Accuracy Before the Audit” panel argued against running prospective and retrospective review as separate programs. Prospective review happens before or during the visit, while the provider still has the chance to document a condition fully. Retrospective review looks back at charts after the claim goes in.
When the two run as one loop, each retrospective finding goes back into provider education and pre-visit preparation, so the same documentation gap doesn’t show up again next year. The goal is correcting upstream, not downstream.
2. With AI, better signal beats more suspects
Speakers pushed back on judging AI tools by how many suspected conditions they flag. A longer suspect list sends more queries to busy providers, and weak flags lead to the documentation problems plans want to avoid. Fewer, stronger suspects backed by clinical evidence in the record serve plans and providers better.
The model on stage splits the work four ways: AI informs, clinicians evaluate, CDI and coding validate, and governance oversees. A clinician’s judgment stays the basis for every diagnosis a plan submits.
3. Audit readiness runs all year, and RADV is more than a coding audit
CMS now audits hundreds of Medicare Advantage contracts each payment year. The Audit-Ready Operating Model panel made the case for treating readiness as a standing operation instead of a scramble when the notice arrives. Panelists described standardized tracking for record intake and retrieval, a named owner for each step, escalation thresholds set in advance, and saved versions of every record along with proof of what the plan submitted and when.
Speakers from Wakely and Jefferson Health Plans added a reminder. A clinically valid diagnosis still fails RADV when the plan has no way to find the record, match the record to the right member and date of service, or submit the record on time. Their approach is to sort every failure by root cause, into documentation, data, retrieval or submission, so each fix goes to the team who owns the problem.
4. Audit rules keep tightening for MA and ACA plans
In September 2025, a federal district court in Texas vacated CMS’s 2023 RADV final rule, which allowed extrapolation of audit findings starting with payment year 2018. CMS has appealed and the case is pending, and in the meantime CMS keeps auditing. Speakers showed how one extra affected member in a 35-member sample is enough to move a recovery from sample-only to extrapolated, so every record in a small sample matters.
On the ACA side, Katy Davis with Sherpas Healthcare Solutions walked through stricter HHS risk adjustment data validation (HHS-RADV) rules for benefit year 2024:
- Medication lists alone no longer support an HCC.
- “Congenital” has to appear explicitly in the record.
- One EMR signature defect now requires a system-wide whitepaper.
- Encounters spanning two benefit years need a whitepaper.
Package 1 for benefit year 2025 is due January 7, 2027.
5. Margin comes from claims, and quality and risk need shared priorities
Max Sungurov with BlueCross BlueShield of South Carolina put the finance picture in simple terms. Accurate revenue capture is table stakes, and margin comes from the claims side. At an 85% medical loss ratio, a plan keeps about a 2% margin. At 90%, the plan sits about 3 points underwater.
Speakers on integrating quality and risk adjustment made a related point. Both teams compete for the same member attention, provider time and budget, so leadership has to agree on what the organization is optimizing for before the teams have a fair shot at delivering.
The forum wraps up Thursday in Orlando.
Risk adjustment, compliance and audit readiness will also be covered at RISE National 2027, March 16-18 at Caesars Forum in Las Vegas.