2027 MA Risk Adjustment: 5 Key Takeaways from the RISE Forum
Big changes are coming to Medicare Advantage risk adjustment in 2027. Healthcare organizations will need to focus more on accurate coding, better documentation, and stronger compliance to avoid financial and regulatory risks. At the 27th RISE Risk Adjustment Forum, held October 27–29, 2026, in Orlando, industry leaders discussed new CMS requirements, increased government audits, and the growing role of AI in healthcare. Here are five important takeaways for Medicare Advantage plans, ACOs, and healthcare providers.
Unlinked Chart Reviews Will No Longer Count in 2027
Starting in 2027, Medicare Advantage plans generally cannot use diagnoses found through chart reviews that are not linked to a patient encounter to calculate risk scores. Diagnoses from audio-only encounters will also be excluded, with an exception for members switching Medicare Advantage plans. This is a major change because many organizations rely on reviewing medical records after patient visits to identify missed diagnoses.
What this means: Providers need to identify and document patient conditions during appointments rather than relying on chart reviews afterward. Since 2027 payments are based on 2026 patient encounters, organizations should already be preparing.
The Government Is Increasing Risk Adjustment Audits
The Office of Inspector General (OIG) is paying closer attention to how Medicare Advantage plans document and report patient conditions. Areas receiving increased scrutiny include:
Diagnoses identified through health risk assessments.
High-risk HCC codes that may lack supporting documentation.
Chart reviews not connected to patient encounters.
Coding practices involving Dual Eligible Special Needs Plans (D-SNPs).
What this means: Healthcare organizations must make sure every reported diagnosis is supported by medical records. They also need to identify and remove codes that lack proper documentation.
Coding Errors Can Lead to Major Financial Penalties
Recent False Claims Act settlements show how costly inaccurate risk adjustment coding can become. Five major settlements discussed at the conference totaled approximately $1.3 billion. These cases highlight the importance of reviewing codes for both missed diagnoses and conditions that should not have been reported.
What this means: Compliance is no longer just about capturing more HCC codes. It's about making sure every code is accurate, supported, and defensible.
AI Can Improve Coding, but Human Review Is Essential
Artificial intelligence is helping healthcare organizations review medical records faster and identify conditions that might otherwise be missed. However, AI recommendations must be checked against actual patient documentation.
The conference also emphasized the importance of preparing for Risk Adjustment Data Validation (RADV) audits throughout the year. Even an accurate diagnosis can fail an audit if the organization cannot quickly locate the supporting medical record.
What this means: The best approach combines AI-powered risk adjustment software with human review, easy access to source documents, and ongoing compliance checks.
Medicare Is Moving Toward Paying for Better Outcomes
The Center for Medicare and Medicaid Innovation (CMMI) continues to introduce programs that reward healthcare organizations for improving patient outcomes rather than simply providing more services. Programs such as LEAD, TEAM, and ACCESS reflect this shift toward value-based care.
What this means: Accurate documentation of patient conditions will become even more important for managing financial risk, improving care, and receiving appropriate reimbursement.
RISE made it clear: Accurate risk adjustment requires earlier coding, stronger documentation, and better compliance.
ForeSee Medical’s AI-powered ESP® software identifies potential HCC conditions, links diagnoses to supporting records with InstaVu®, and flags documentation gaps. Its new Catch & Release™ capabilities help verify documentation before claims are submitted—improving RAF accuracy, reducing chart review time, and strengthening audit readiness.Don’t wait for an audit to uncover problems. Request a demo to prepare your organization for 2027.
Blog by: The ForeSee Medical Team