What to Look for in a Risk Adjustment Vendor in the Era of CMS HCC V28

The rollout of CMS HCC V28 has forced healthcare organizations to reevaluate how they manage risk capture, coding accuracy, and documentation quality. These shifts come with tighter criteria, new exclusions, and increased scrutiny—especially in how hierarchical condition categories (HCCs) are supported and coded. This transition has elevated the importance of choosing the right Risk Adjustment Vendors—not just for technology, but for strategic guidance, compliance readiness, and real-time adaptability. The right partner will help you navigate complexity, preserve revenue, and stay compliant in a post–V24 world.

Why the CMS HCC V28 Update Changes Vendor Expectations

The CMS HCC V28 update significantly reshapes risk adjustment by excluding many previously accepted conditions, emphasizing documentation specificity, and tightening coding requirements. Generalized codes now fall short; detailed and accurate documentation aligned precisely to the new CMS standards is mandatory. Healthcare providers and coding teams require robust support to adapt swiftly to the altered hierarchies and exclusions. Static, retrospective-only vendor solutions are no longer adequate. Today’s vendors must be dynamic, forward-looking, and deeply integrated into clinical workflows to ensure continuous compliance and optimal risk capture.

Core Capabilities Every Risk Adjustment Vendor Should Offer in the V28 Era

Model-Aware Technology

Risk Adjustment Vendors should clearly demonstrate their technology’s alignment with CMS HCC V28. This includes updated HCC groupings, real-time coding updates, and configurable alerts for identifying potential risk conditions that comply with the latest CMS model.

Integrated Clinical and Coding Support

Effective vendors provide end-to-end support, aiding clinicians in precise documentation and empowering coders with tools to reflect the true patient risk accurately. Such solutions utilize MEAT (Monitor, Evaluate, Assess, and Treat) evidence and audit-ready validation methods.

Pre-Encounter and Point-of-Care Intelligence

Prospective risk adjustment has moved from optional to essential. Vendors should offer comprehensive pre-visit insights and point-of-care alerts that allow clinicians to address HCC gaps in real-time, significantly enhancing documentation accuracy.

CDI and Provider Training Programs

Comprehensive training tailored to specific provider specialties is essential. Vendors must educate clinical staff on V28 changes and facilitate seamless documentation behavior adjustments without disrupting clinical workflows.

Flexibility and Custom Reporting

Risk Adjustment Vendors must provide detailed analytics on how V28 changes impact RAF scores, compliance rates, and audit preparedness. Customizable dashboards, scenario modeling, and performance analytics aligned with V28 criteria ensure informed strategic decision-making.

Proven Audit Defense Framework

Given CMS’s intensified audit activity, robust audit trails, defensible documentation, and systematic compliance checks beyond mere claims logic are indispensable. Vendors should provide clear, detailed evidence supporting each submitted HCC code.

Signs of an Outdated Vendor You Should Avoid

• Reliance on outdated CMS V24 logic without clear pathways for automated V28 updates.
• Absence of prospective coding solutions or real-time documentation validation.
• Limited provider engagement, focusing exclusively on retrospective coding teams.
• Inflexible technology integrations or restrictive reporting capabilities.
• Poor visibility linking submitted codes back to source documentation.

Partnering with outdated vendors significantly increases compliance risk, jeopardizes revenue integrity, and places unnecessary stress on clinical and coding teams.

Questions to Ask During Vendor Evaluation

1. How have your technology and workflows adapted specifically to CMS HCC V28?
2. Can your solutions proactively identify HCC opportunities in real-time clinical interactions?
3. What training programs do you offer to providers for adapting to CMS documentation changes?
4. How effectively does your solution track and report missed HCC opportunities under V28 guidelines?
5. Can your platform accurately forecast our RAF score transitions from V24 to V28?

Detailed, transparent answers to these questions indicate readiness and reliability, helping healthcare organizations thrive under the new model.

Long-Term Partnership Value

Selecting a Risk Adjustment Vendor is more than a short-term technology decision. Vendors should not only meet current V28 requirements but demonstrate the agility to anticipate future CMS updates and evolving regulatory demands. The most valuable partnerships are grounded in continuous improvement, clear communication, shared accountability, and measurable outcomes in compliance, coding accuracy, and revenue optimization.

Closing Thoughts

Choosing the right Risk Adjustment Vendors in the wake of CMS HCC V24 to V28 isn’t just about software. It’s about partnership, preparedness, and performance. As risk models evolve and compliance demands tighten, organizations need vendors who bring both technical precision and human support—helping your teams stay ahead of changes, not scramble to catch up. The right decision now can safeguard your revenue, your reputation, and your confidence going forward.