Risk Adjustment is Changing. Are You Ready to Evolve or Risk Extinction?
If risk adjustment were a chess game, the V28 model for 2025 is the moment your opponent upends the board. Medicare Advantage plans and risk-bearing providers are no longer playing by familiar rules. The transition to V28 with a 67%/33% blend represents not just a change, but a complete system recalibration.
This isn’t incremental. It’s transformational. The question is: Are you evolving fast enough to survive the transformation?
In a world where precision is paramount and agility is mandatory, the new risk adjustment landscape offers two choices — adapt with surgical accuracy or face obsolescence.
Decoding V28: The Core of the Shift
The introduction of V28 isn’t a minor tweak; it’s a fundamental overhaul of the risk adjustment model. Here’s what you need to understand about this shift:
● Over 2,000 Diagnosis Codes Eliminated:
The familiar safety net of broadly applicable codes is gone. The codes that allowed flexibility in diagnosis capture have been stripped away. If your coding practices don’t evolve, expect significant revenue losses.
● More Hierarchical Condition Categories (HCCs):
While the number of HCCs is increasing, the mappings are now tighter and less forgiving. The new model demands surgical precision in coding. Approximation is no longer an option; specificity is everything.
● 3.12% Average Payment Reduction:
For many plans, this translates into millions in lost revenue. This reduction won’t be felt evenly — plans with historically inconsistent coding practices will experience the harshest declines.
● The 67%/33% Blend:
In 2025, CMS will calculate risk scores using 67% V28 and 33% V24. This blend offers a fleeting window to adapt. By 2026, the transition to V28 will be complete. Think of this as a countdown clock, not a grace period.
V28 is a seismic shift. To survive, your coding strategies, processes, and technologies must be recalibrated — now.
Challenges for Risk-Bearing Providers: Precision is the New Survival Strategy
For risk-bearing providers, the transition to V28 is a high-stakes challenge. The demands for accuracy and efficiency are higher than ever. Here’s how to meet those demands head-on:
Capture Diagnoses with Surgical Precision
Every diagnosis must be captured with absolute specificity. The elimination of codes means there is no room for ambiguity. Missed or vague diagnoses are no longer just mistakes — they’re direct hits to your revenue.
Embrace Real-Time Coding
Retrospective corrections are too slow and too risky. Diagnosis capture must happen at the point of care, ensuring that every opportunity is seized immediately. If your processes lag, you’re bleeding revenue.
Elevate Documentation Standards
Coding precision must be supported by robust documentation. Vague clinical notes or incomplete records are liabilities waiting to be exploited. Every diagnosis should be backed by clear, detailed evidence that can withstand scrutiny.
Invest in Continuous Education
The shift to V28 requires more than a one-time training session. Providers need ongoing education, real-time feedback, and support tools that guide accurate coding during patient encounters. Staying sharp is no longer optional — it’s essential.
Health Plans: The Imperative to Transform
For health plans, V28 is a crucible that will separate the adaptable from the obsolete. Thriving under V28 requires a fundamental transformation of your risk adjustment processes.
Invest in Adaptive Technology
Static systems are relics of the past. Your technology must evolve dynamically with the risk model. Platforms that offer real-time data integration and dynamic HCC mapping are no longer luxuries — they’re necessities.
Leverage Scenario Modeling
The 67%/33% blend offers a brief opportunity to anticipate and mitigate revenue impacts. Run multiple scenarios:
● What happens if your coding accuracy drops by 5% or 10%?
● How will different levels of provider engagement affect your bottom line?
Use these insights to build contingency plans that ensure agility under pressure.
Achieve Seamless Integration
Siloed systems create inefficiencies and errors. Your technology must unify risk adjustment, claims processing, and provider engagement into a single, cohesive workflow. Integrated systems reduce errors, enhance compliance, and streamline operations.
How Allymar Health Positions You for V28 Success
In the turbulent landscape of V28, Allymar Health offers the clarity and support you need. The Medicare Advantage Suite is designed to meet the exacting demands of the new risk adjustment model.
● Real-Time Coding Precision:
Capture accurate diagnoses at the point of care, helping to eliminate errors and maximizing opportunities.
● Dynamic Adaptation:
The Suite evolves seamlessly with V28, enhancing your HCC mappings and diagnosis codes so that they are current and compliant.
● Integrated Workflows:
No more silos. Allymar Health unifies risk adjustment, claims processing, and provider engagement, delivering streamlined efficiency.
● Predictive Analytics and Scenario Modeling:
Forecast utilization patterns, model potential revenue impacts, and develop actionable strategies to stay ahead of the curve.
● Continuous Provider Engagement:
Empower providers with ongoing education, real-time feedback, and intuitive tools for accurate, compliant coding.
V28 is the New Reality. Allymar Health Helps You Master It.
The clock is ticking. By 2026, the transition to V28 will be complete. The winners will be those who embrace precision, adaptability, and strategic foresight. The losers will be those who wait and hope.
With Allymar Health, you’re not just surviving V28 — you’re mastering it.
Are you ready to lead in the future of risk adjustment?
