RADV audits just got real. In 2025, Medicare Advantage (MA) plans are facing the true financial impact of inaccurate or incomplete risk adjustment coding.
With CMS enforcing stricter RADV extrapolation rules and intensifying HCC validations, the message is clear: risk adjustment compliance and accurate HCC capture are not optional.
For Medicare Advantage plans, ACOs, and risk-bearing provider
A recent HFMA study shows that hospital CFOs see revenue cycle – especially medical billing accounts receivable and denials management – as the biggest area of opportunity for AI [1]. This raises a key question: what do revenue cycle leaders need to do to prepare? Considering the complexity of AI technology, choosing a good partner with “pre-AI” revenue cycle expertise is
Physicians have expressed concern over payers using artificial intelligence automation, and with good reason. The AMA reports that AI tools contribute to a dizzying increase in denial rates – up to 16 times the norm [1]. So it’s only logical that many providers are looking for ways to “fight AI with AI”, especially in the area of risk adjustment services for U.S. healthcare organizations.
Medical risk coding risk adjustment in healthcare is an excellent use case for AI solutions. When well trained, these models can improve coding accuracy – they stay on top of guidelines to support compliant coding practices, even identifying risk adjusted codes in both unstructured and structured text. It’s a huge potential benefit in supporting complete code capture. At the same time, it can grant leadership increased visibility through improved reporting and project management support – critical for effective medical coding risk adjustment operations.
Looking at the range of potential benefits that AI offers in enhancing risk adjustment services, many leaders see an opportunity (or threat) as a replacement for human coders. This is a misguided way of looking at the technology. It’s critical to remember that, even though the work of coding is heavily numerical and structured, the complexity of medical records and the variation in documentation styles of clinicians means that a human touch is still needed. Even the best-trained AI cannot fully understand a medical record the way a certified coder can.
This means that leaders looking for options to implement AI in risk adjustment in healthcare should move away from either-or thinking, instead taking a both-and approach to how they implement AI and human coders. This is the spirit we’ve leaned into when developing RiskGen-i our AI-powered platform for the nuances of HCC medical coding risk adjustment management. Built to complement the efforts of certified coders, this platform is an ideal solution for leaders who want to do more with the coding resources they have.
And for organizations seeking a fully human-led model, our RiskGen-Core platform delivers the same high standards of accuracy, compliance, and productivity – without AI assistance.
We invite U.S. healthcare leaders to explore how RiskGen-i and RiskGen-Core can help transform your risk adjustment services – boosting compliance, accuracy, and efficiency in today’s challenging reimbursement landscape.
References
[1] American Medical Association, “Physicians concerned AI increases prior authorization denials,” 24 February 2025. Available: https://www.ama-assn.org/press-center/ama-press-releases/physicians-concerned-ai-increases-prior-authorization-denials.
Hemant Apte, Chief Executive Officer in
Hemant Apte, Founder & Chief Executive Officer of 3Gen Consulting, is a seasoned executive leader with deep domain expertise in US healthcare management practices. He founded 3Gen Consulting in 2006 and has been instrumental in offering thought leadership to his clients and providing services and solutions that are unique in the market.
In today’s value-based healthcare environment, risk adjustment medical coders are essential to the financial health, regulatory compliance, and care quality of U.S. healthcare organizations. As CMS continues to evolve its HCC risk adjustment models and intensify audit scrutiny, the expertise of these professionals plays a pivotal role in ensuring accurate reimbursements and minimizing risk.
This blog explores the evolving responsibilities of risk adjustment medical coders, the impact of their work on HCC risk adjustment coding, and best practices for healthcare providers looking to
Changes from the Centers for Medicare & Medicaid Services (CMS) have been plentiful in recent months—and now things are ramping up for risk adjustment coding.
Revenue cycle leaders working with Medicare Advantage (MA) plans and risk adjustment management will benefit from staying on top of recent changes in medical coding in USA. To help you in this task, we’ve put
