Navigating CMS Risk Adjustment Model V28: Key Strategies for 2025

Next year marks the third year of the phase-in period for CMS Risk Adjustment Model V28. This model introduces clinically-based technical updates aimed at improving payment accuracy for Medicare Advantage (MA) plans. However, these changes also mean that providers must operate more efficiently to maintain their funding levels—and with 2025 just around the corner, it’s essential for provider organizations to refine their risk capture strategies.

The Importance of a Robust Risk Adjustment Strategy

Success under CMS’ new model hinges on three interconnected strategies:

• Education: Providing both general and specific training opportunities for providers to ensure they understand the nuances of the new model
• Clinical Documentation: Ensuring precise, accurate, and complete clinical documentation to capture all relevant risk-adjustable conditions
• Technology: Utilizing advanced technology solutions to support clinicians. This includes automation for HCC recapture, identifying new clinical conditions, and enhancing notifications and queries with NLP-based intelligence

Why This Matters

According to a recent AAPC study, providers and coders have a 14% coding error rate, which can lead to significant financial losses. At an estimated value of $2,500 per HCC, this error rate represents an average annual loss of $527,500 for provider organizations in the study. Understanding and improving your organization’s coding accuracy and specificity is essential, especially with the upcoming changes to the CMS risk adjustment model.

How Edifecs Can Help

To help provider organizations navigate these changes, Edifecs is offering a free 60-minute consultation to evaluate your risk adjustment strategy and impact planning for 2025. During the consultation, we will:

• Assess your current program using data points you provide
• Calculate and forecast your 2025 reimbursement and savings
• Explore “what-if” scenarios based on real-world performance data

Take Action Now

2025 is a pivotal year for risk adjustment. By signing up for our free consultation, you can ensure your organization is well-prepared to maximize reimbursement and minimize financial risks. Don’t miss this opportunity to refine your strategy and stay ahead of the curve.

For more information and to schedule your consultation, please fill out the form linked here. Let’s work together to make 2025 a successful year for your organization.