Insights That Move Healthcare

The New Era of HCC Risk Adjustment: Why Defen...

For years, many Medicare Advantage organizations treated HCC risk adjustment as a volume exercise: capture more diagnoses, lift RAF scores, and increase reimbursement. That approach still looks attractive on paper, but in 2026 it’s increasingly unsustainable. CMS audit activity has intensified, CMS-HCC Version 28 has reshaped risk coefficients and mappings, and quality programs like HEDIS are more tightly linked to accurate documentation. The result: the question has shifted from “Was the diagnosis submitted?” to “Can the diagnosis survive scrutiny?”