V28 Fully Phased-In: Payers and Providers Struggle to Keep Up

In 2025, the transition to CMS’s Hierarchical Condition Category (HCC) Version 28 continues to create widespread disruption across the healthcare ecosystem. Now that it’s fully phased-in, V28 is reshaping how Medicare Advantage (MA) plans assess risk, document patient conditions, and ultimately get paid. The result? A wave of financial strain, operational stress, and strategic recalibration among both payers and providers.

What Changed Under HCC V28?

V28 introduced a more granular and clinically refined framework for risk adjustment. Compared to Version 24, which had been in place since 2014, V28 features:

• An increase in total HCCs from 86 to 115, with significant reclassification and removal of conditions that no longer meet CMS’s threshold for predictive cost.

• Elimination of over 2,000 ICD-10 codes from risk mapping.

• More emphasis on severity and specificity in diagnosis documentation.

• Removal of codes related to historical conditions no longer actively managed (e.g., some types of diabetes with resolved complications such as diabetic retinopathy that has stabilized or resolved due to treatment, such as laser therapy or surgical intervention.

These changes are meant to improve coding accuracy and ensure risk-adjusted payments reflect only active, high-cost conditions. But for MA plans and providers, the impact has been seismic.

The Pressure Mounts

In 2024, CMS implemented a blend of 67% V24 and 33% V28 for calculating RAF scores. That year, many organizations saw moderate payment reductions and began preparing for a steeper cliff.

In 2025, the blend shifted to 100% V28, eliminating the buffer and exposing the full revenue impact. Across the industry, many organizations are reporting:

• Declining average RAF scores, even in populations with unchanged clinical complexity.

• Revenue shortfalls compared to prior years due to the narrowed scope of reimbursable conditions.

• Increased documentation burden, as V28 requires more detailed coding specificity to support each risk-adjusted condition.

The Struggle to Keep Up

For many payers, particularly those with historically high RAF scores under V24, the transition has triggered substantial revenue losses. This has been especially painful when paired with rising utilization and higher medical loss ratios (MLRs).

For providers, the challenge is equally daunting. Traditional coding workflows—especially those reliant on retrospective chart reviews or generic EHR prompts—often fail to meet the stricter documentation standards of V28. Without proactive, point-of-care support, providers may miss conditions, under-code severity, or fail to include required documentation elements, leading to denials or lost risk capture.

The Risk of Unengaged or Undocumented Populations

One less visible—but growing—problem under V28 is how poorly documented or newly onboarded patients affect RAF performance. As MA plans consolidate or acquire members from exited markets, they often inherit:

• Unengaged patients with little history of preventive care or wellness visits.

• Sparse documentation, making accurate risk scoring difficult in the short term.

• Higher utilization, without corresponding RAF support under the stricter V28 model.

When these patients consume care but lack risk-adjusting documentation, the result is a cost-revenue mismatch that hits MA plans hard.

A Real-World Example: Industry Leaders Are Not Immune

Even the largest organizations have struggled. UnitedHealth Group recently cut its 2025 earnings guidance, citing rising senior utilization and challenges adapting to V28. Its care delivery arm, Optum Health, is facing pressure from newly acquired MA members and insufficient RAF capture under the updated model. While their situation is specific, it underscores the broader industry reality: V28 has changed the rules of engagement.

What’s Needed to Succeed Under V28?

To weather the storm, payers and providers must retool their approach to risk adjustment. Key strategies include:

• AI-driven HCC coding software that can uncover undocumented conditions at the point of care.

• Enhanced clinical documentation support to ensure diagnoses meet V28’s stricter coding thresholds.

• Real-time provider education and feedback loops, helping clinicians code more accurately and comprehensively.

• Better member engagement, particularly for high-risk or newly acquired populations who may have care gaps and insufficient histories.

Looking Ahead

HCC V28 represents a structural shift in risk adjustment—and it’s not going away. While 2026 won’t include further model changes, the damage (or success) will already be visible in 2025 financials. Organizations that invest in smarter technology, tighter workflows, and better documentation support will be better positioned to navigate this evolving landscape.

Built for the V28

ForeSee Medical simplifies the complexities of HCC V28 with AI-powered risk adjustment tools that work in real time. Our risk adjustment software platform surfaces undocumented conditions, ensures coding meets stricter V28 standards, and delivers point-of-care support directly in the EHR. Whether you're facing declining RAF scores, onboarding new members, or tightening compliance, ForeSee helps you stay accurate, efficient, and financially resilient in the face of V28.

Blog by: The ForeSee Medical Team