Risk Adjustment Reality Check: What’s Working—and What Isn’t

This year has been something of a reckoning for Medicare Advantage. Senator Grassley’s scathing report of UHG’s risk adjustment practices, and the Kaiser $556 million settlement to resolve False Claims Act allegations of upcoding, opened eyes, and got many in the industry talking. I wanted to get someone on the show with opinions, unafraid to speak their mind and share their perspective. I’ve found that person. Betty Stump is Senior Solution Consultant for Edifecs, a Cotiviti Business. She is in the business of risk adjustment and value-based care on the vendor side, but is never afraid to offer her opinion on the industry, pro and con. And with more than 20 years in the industry across multiple well-known companies, it’s an informed one. Listen in as we discuss: What is working in value-based care/risk adjustment—and where have we gone wrong? Recent conference disillusionment. Kaiser DOJ fine and the Grassley report taking aim at UHG’s aggressive risk adjustment strategy: Betty’s thoughts and where does this heightened era of scrutiny put risk adjustment coders. Do we need to elevate the MEAT standard? What are organizations missing with risk adjustment? Great, practical, low-tech suggestions for RAF capture including using your 2025 end-of-year roster to identify those patients with high-risk conditions and engage in proactive outreach to get patients seen. V28 of CMS-HCCs with V24 in the rear-view mirror. Truthful tech talk: How leaders can get a seat at the table, how to get a vendor’s ear to modify functionality, and truth and hype in CDI tech How should a CDI or coder interact with a machine prompt from a suspecting tool? Looking back at a colorful 20-year career in the consulting life, and a thoughtful selection for the Off the Record Spotify playlist by a fellow music enthusiast.