Navigating the Future of Risk Adjustment: Preparing for 2026
The landscape of healthcare risk adjustment is constantly evolving, and staying ahead is crucial for the financial health of Qualified Health plans (QHPs). Recent data reveals that risk transfer totals for the 2023 benefit year reached nearly $20.6 billion. This signifies a substantial flow of $10.3 billion from plans serving healthier populations to those with higher-risk members, and vice versa.Understanding these dynamics is more important than ever as we look toward 2026 and important changes in how risk adjustment operates. You need a proactive strategy to ensure success.
What’s Changing in 2026?
The Department of Health and Human Services (HHS) has outlined key updates in the Notice of Benefit and Payment parameters for 2026. These changes require a careful review of your current risk adjustment programs.Here’s a breakdown of the areas demanding your attention:
Coverage Design: Rethinking your plan benefits can considerably impact risk scores.
Risk Adjustment Data Validation (RADV) Audit Methodology: The way audits are conducted is evolving, demanding a more robust data validation process.
HHS Risk Adjustment User Fee & Medical Loss Ratio (MLR) Regulations: New regulations surrounding user fees and MLR calculations will affect your financial planning.
Building a stronger Risk Adjustment Program
Successfully navigating these changes requires a strategic approach. It’s about more than just compliance; it’s about optimizing your program for accuracy and financial stability. Here are key areas to focus on:
Leverage the Power of Analytics: Data-driven insights are essential for identifying risk adjustment opportunities and potential audit vulnerabilities.
Invest in Provider Education: Empowering your network with accurate coding practices is fundamental to capturing a complete and accurate risk picture.
Prioritize Member Engagement: Proactive engagement can improve data accuracy and ensure members receive the appropriate care.
Strengthen Audit Strategies: A well-defined audit process will help you identify and address potential issues before they become problems.
Why Preparation Matters Now
Don’t wait until 2026 to address these changes. Proactive preparation is the key to improving risk score accuracy and optimizing your programs. By taking action now, you can:
Enhance Financial Stability: Accurate risk scores translate to appropriate payments, bolstering your financial health.
Minimize Audit Risk: A robust program reduces the likelihood of costly RADV audits and potential penalties.
Improve Member Care: Accurate risk adjustment ensures resources are allocated to those who need them most.
taking the time to understand these changes and implement a strategic plan will position your QHP for success. It’s an investment in your future, and a commitment to providing quality care to your members. Don’t miss this opportunity to strengthen your risk adjustment program and prepare for a smooth transition into 2026.
[Download our white paper to learn more about navigating these changes and building a prosperous risk adjustment program.](https://blog.cotiviti.com/hs/cta/wi/redirect?encryptedPayload=AVxigLJNb1yE8QC6gbwjBjiuSmOOmhQdzHkuGRir%2FJ%2FEt8K8H%2FdNgaJOJ9rOdhlqaUR%2FevY5jBaUz6zxYelu%2BnesNvKg7F4EUaU6FlqQL5OfMwJ3jM0nDA858O%2FZvZ7fJ%2BAonKKgX3NBPdEr70gG5DCTmDpjoKT4JhmHmbmEmpBffwHVUZixTApI%2FcE53XaKhxOSOyqlFgu31edpcm2kxQRizT1N8L0
