Assessing V28: four key questions all payers need to ask 

It’s officially here: this year, all services paid for by Medicare will be evaluated under the Center for Medicare and Medicaid Services' Risk Adjustment Model V28. Health plans have experienced a gradual transition to V28 over the past three years. But what will 100% use of V28 mean for your plan, risk adjustment processes, and success in value-based care?

What is Risk Adjustment Model V28, and how does it impact value-based care?

V28 is the latest model Medicare has developed to predict costs and determine reimbursements. CMS’s aim is for the new model to more accurately capture patient risk and therefore provide a more precise calculation for reimbursement. Ultimately, CMS expects to reduce overpayments to payers. Healthcare organizations preparing for V28 must have strategies in place to improve the accuracy of their documentation to avoid a reduction in reimbursement.

The transition from Risk Adjustment Model V24 to V28

The transition to V28 has been a major effort by CMS with a multi-year phase-in. Designed to increase risk adjustment data accuracy and reduce overpayments, the new model increases the number of Hierarchical Condition Categories (HCCs) from 86 to 115. It also shifts the focus away from the volume of a patient’s diagnoses to their severity to get a more precise measurement of member health.  

That added precision may come at a price for health plans. As a result of increased specificity and a focus on severity, CMS projects overall risk scores will decrease, possibly resulting in lower reimbursement rates.

To mitigate any impact on financial performance and get a true sense of the impact of the transition to V28, payers should already have transition plans underway and be assessing the impact of V28 now. Here are four questions all payers should ask to get a complete picture of the impact of V28 and ensure success in value-based care—regardless of the specific model CMS uses to measure risk.

Evaluate the impact of V28 with these four key questions

Question #1: How accurate is your documentation?

One of CMS’s central goals for the transition to V28 is to base reimbursement on a more accurate and clinically meaningful picture of member health. For payers, that means doing everything possible to ensure the completeness and precision of your data.

One way you can do this is by tapping into additional clinical data sources to measure risk. External data such as prescription information, lab results, and data from health information exchanges (HIEs) can reveal a more comprehensive view of each member’s health status beyond the four walls of your network. This data can even uncover any missed or uncoded diagnoses.  A richer data foundation supports more accurate risk adjustment and helps ensure appropriate reimbursement, even for patients who aren’t regularly engaging with the healthcare system.  

Additionally, leveraging artificial intelligence (AI) can help support clinicians in improving the quality of their documentation both before and after a patient encounter. AI-powered technology can help uncover clinical evidence that aligns with M.E.A.T. (Monitor, Evaluate, Assess, Treat) standards and close documentation gaps for suspected diagnoses. Following the patient encounter, AI can help verify documentation accuracy during the medical record review process.  

Pro tip: Some previously accepted diagnosis codes are not accepted under the V28 model. Therefore, you may have to go deeper to measure risk, better understand patient condition severity, and get an accurate accounting of complex conditions.

Question #2: Are you targeting your highest-risk patients?

Under V28, severity—not just quantity—of diagnoses takes precedence. For example, a patient with both a diagnosis of diabetes as well as high blood pressure may now carry a higher risk score. This is because the more severe HCC takes precedence as opposed to a patient’s total number of diagnoses—payers cannot use both HCCs for risk adjustment.

This change raises the stakes for identifying and actively engaging your highest-risk members. Health plans should prioritize outreach to patients with chronic or complex conditions that carry high severity weights under V28. Accurately capturing the true clinical impact of these conditions is the key to aligning reimbursement with the actual cost of care.

Pro tip: To do this effectively, payers can support clinicians with predictive analytics and risk stratification tools that surface members whose conditions may be under-documented or at risk of progression. When you equip clinicians with relevant, timely data before and during patient encounters, you can help make sure they address and document these conditions appropriately.

Question #3: Are providers on board?

To make patient targeting successful and improve the accuracy of documentation, payers need to prioritize clinician engagement. Make sure to clearly communicate what the transition in risk adjustment models means and how it impacts providers directly. That includes explaining the shift in focus from diagnosis count to severity and how the shift can influence performance metrics, shared savings, and other value-based payment arrangements.  

It’s equally important to provide actionable guidance. Are clinicians aware of which diagnoses are no longer valid under V28? Do they understand how to align documentation with M.E.A.T criteria to capture HCCs accurately? Have they been equipped with tools or resources—such as AI-generated clinical insights—that support decision-making at the point of care?

Pro tip: Build a feedback loop with clinicians, offering ongoing education, timely data, and performance insights. When providers understand the risk scorning changes and are prepared with key clinical insights, they are more likely to be strong partners in enhancing patient outreach and enriching their documentation.

Question #4: Do you have a reliable way to forecast revenue, and what’s the result of your financial performance?

Because CMS indicated it expects overall risk scores to decline, you must have a plan in place to predict the financial impact of the transition. The results can guide strategic decision-making—helping you plan budgets more accurately and adjust intervention strategies accordingly. This information will also help inform conversations with providers about potential changes to risk scores, the impact on reimbursement, and the urgent need for highly accurate documentation.

Pro tip: Revenue forecasting is about enhancing visibility and preparedness for both payers and providers. Leveraging advanced member management technology can help you run revenue impact calculations to determine possible impacts on your overall performance and the impact on your membership.

Pulling it together: wrapping up your V28 assessment

Though by some estimates the Risk Adjustment Model V28 will result in lower risk scores than V24, payers who ask themselves these four critical questions are best positioned for success under the new model. Make sure your teams carve out time to work cross-functionally across actuarial, coding, and clinical teams to assess your documentation, patient targeting, clinical collaboration, and financial performance.  

When viewed strategically, the transition to V28 can be more than a change in compliance requirements. Health plans can use this opportunity to improve documentation, drive improved outcomes, and better align care delivery with reimbursement.

Reveleer’s value-based care enablement platform, powered by AI, can help support payers in the transition to V28 by:

• Aggregating and centralizing data from multiple sources, building a more complete picture of patient health.

• Surfacing actionable insights in the data to help payers target high-risk patients.

• Integrating into EHRs and provider workflows to facilitate clinical collaboration.

• Conducting highly accurate and CMS-compliant revenue forecasting to guide strategic planning.

V28 is here, so don’t wait to act. Start by answering these four critical questions to assess the impact on your organization. Then, come up with strategies to find success under the new model, continually driving improvements in cost and quality.  

Interested in a dedicated technology partner to support the transition? Schedule a demo with Reveleer to learn more about our advanced platform for value-based care.

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