Top 5 Takeaways for Strengthening Risk Adjustment in 2025
- Martha Goodlin
- May 27
- 2 min read
Insights from the 2025 RISE Risk Adjustment Forum
As CMS ramps up oversight and plans prepare for V28 and RADV expansion, the 2025 RISE Risk Adjustment Forum highlighted what’s top of mind for risk adjustment leaders across the country. The message was clear: success in 2025 depends on smarter strategy, cross-functional coordination, and proactive compliance.
Here are five key takeaways to guide your risk adjustment efforts in the year ahead:
1. Internal Auditing Is No Longer Optional
Panelists emphasized that internal audits are now table stakes. By identifying documentation gaps and coding discrepancies before CMS does, plans can reduce risk, improve data integrity, and strengthen financial performance. Audit-readiness must be built into the day-to-day—not just a year-end event.
2. Provider Engagement Drives Accuracy
Accurate risk adjustment starts with provider documentation. Leading plans are investing in provider-facing dashboards, targeted education, and performance feedback loops. The most effective programs don’t just push information—they foster collaboration and close gaps at the source.
3. Integrating Risk Adjustment and Quality Is Key
Forum speakers repeatedly pointed to the benefits of aligning quality and risk adjustment teams. Integrating data, outreach, and education efforts across these two programs reduces duplication and leads to stronger outcomes—both clinically and financially. It’s a win-win for members and plans alike.
4. RADV and V28 Are Raising the Stakes
The release of new RADV audit results and extrapolation methodology, paired with the shift to Version 28, is forcing plans to evolve. Regulatory scrutiny is rising, and staying ahead requires scenario planning, documentation accuracy, and team education on how V28 affects both risk capture and coding strategy.
5. AI and NLP Are Gaining Ground—But Caution Is Key
Artificial Intelligence and Natural Language Processing are helping plans uncover missed diagnoses and streamline documentation. But CMS has made it clear: these tools must be auditable, transparent, and compliant. Technology can enhance workflows—but it must support, not replace, sound clinical judgment.
How Rebellis Group Can Help
At Rebellis Group, we help health plans strengthen their risk adjustment and compliance strategies—so you're not just keeping up with CMS, you're staying ahead.
Whether you're preparing for RADV, adapting to V28, or aligning internal teams, we offer end-to-end support that includes:
Retrospective Audit Support – Comprehensive mock audits to identify vulnerable diagnoses before CMS does.
Extrapolation Risk Modeling – Quantifying potential financial exposure and advising on mitigation strategies.
Clinical Documentation Reviews – Ensuring HCCs are fully supported with complete and compliant medical records.
Provider Engagement & Education – Including documentation reviews, dashboards, and feedback loops.
Coding & Compliance Training – Equipping your team with up-to-date guidance and practical strategies.
Ongoing Compliance Monitoring – Designing and implementing internal controls aligned with CMS’s evolving audit criteria.
Interim Staffing Support – Deploying experienced, certified coders to assist with chart reviews, documentation validation, and audit preparation—helping your team meet CMS deadlines without overextending internal resources.
Risk Adjustment and Quality Integration Strategy – Aligning departments to improve clinical and financial outcomes.
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