Medicare Advantage · Program Integrity

v28+RADV

V28 changed the math. RADV will test it.
PopulationManager makes the gap legible, 1 Member at a time.

Meet a Medicare Advantage Member

Her plan submitted 12 diagnosis codes for her in 2024. Each code that maps to an HCC adds to her RAF score. Each RAF point adds dollars to the monthly capitated premium CMS pays the plan for her.

HCC 17Diabetes with chronic complications · retained under V28
HCC 22Morbid obesity · recalibrated under V28
HCC 36Diabetes without complication · retained
HCC 85Congestive heart failure · retained
HCC 96Specified heart arrhythmias · retained
HCC 111Chronic obstructive pulmonary disease · retained
HCC 138Chronic kidney disease, stage 4 · retained
HCC 189Amputation status, lower limb · retained
gapCode condensed or dropped under V28 — once paid, now compressed
gapCode condensed or dropped under V28 — once paid, now compressed
gapCode condensed or dropped under V28 — once paid, now compressed
gapCode condensed or dropped under V28 — once paid, now compressed
8 codes — diagnosis in chart, clinical evidence backs it up. Legitimate HCCs. 4 codes — diagnosis on bill, no clinical evidence in chart. CMS still pays.
4 of 12 codes = the gap. Where the upcoding lives. PopulationManager closes it.
Clinical what the chart says Claims how the system behaves PopulationManager Natively Bilingual
Clinical onlyEHR · labs · meds · vitals · problem list · clinical notes. What the chart actually says about this Member.
PopulationManagerWhere Clinical + Claims fuse, Member-by-Member, code-by-code. Natively bilingual. The four-state taxonomy is built here.
Claims only837 claims · MMR · enrollment · authorizations. How the system actually behaved for this Member.
EHR · labs · meds · vitals · problem list ↔ 837s · MMR · enrollment · authorizations

The FHG Answer to V28 + RADV

FHG makes V28 + RADV legible, 1 Member at a time.

Clinical and Claims, Fused. Natively Bilingual.

  • +Year-over-year HCC qualification tracking.See, by Member, which conditions qualified last year and which qualify this year — the V28 story in one row.
  • +Risk-score variance to baseline.Quantify V28's compression on raw and normalized RAF, with Member-level traceability back to the qualifying ICDs.
  • +The four-state taxonomy.Documented + Supported · Documented Only · Not Documented But Supported · Neither. Every Member-code lands in exactly one cell.
  • +Network-role segmentation.Separate Employed, Affiliated, Private, and Other claim activity to see where score is being captured — and where it's leaking.
  • +Plan-Assigned-PCP attribution.Surface the gap between Members on a PCP's panel and Members whose claim activity actually flows through that PCP.
  • +ICD-to-HCC traceability.Every score contribution backed to the specific ICD codes that produced it — auditable on demand.
  • +Audit-defensible documentation.Focus diagnostic-support work where the math actually moves — before the auditors arrive, whichever side of the audit you're on.
  • +HCC/RAF scoring modules + executive dashboards.Roll-ups for the C-suite; scorecards for the panel; one connected story.
  • +Performance and Behavior of the Clinical Network.Aggregate-view across all Members — where the score comes from, where it leaks.

Every Member-code lands in one cell

The four-state taxonomy of V28 risk adjustment.

Diagnosis on the bill × evidence in the chart.

Documented + Supported

"The legitimate HCCs · what the system should pay for."

Sample Member77yo with T2D + polyneuropathy. Chart confirms E11.42 in three notes. Claim carries E11.42. RAF: 0.302.The clean HCCs — exactly what CMS expects you to report.
⚠

Documented Only

"The upcoding vector · where the dollars at risk live."

Sample Member60yo with E11.42 on every claim. Chart documents uncomplicated diabetes only. No clinical evidence for the chronic-complications upgrade.Where RADV extrapolation hits hardest. Audit-defensible documentation work happens here.

Not Documented But Supported

"The missed code · revenue left on the table."

Sample MemberChart documents CKD stage 3 across three encounters. No claim carries N18.3. RAF lost: 0.289.Recoverable with PopulationManager's chart-side surfacing. Real revenue, never billed.

Neither

"No diagnosis · no evidence · no signal · out of scope."

Sample MemberNo claim activity. No chart evidence. No HCC qualifies.Most of any Member panel sits here for any given HCC at any given time. Out of scope.

Documented Only is where the dollars at risk live. Not Documented But Supported is where revenue is left on the table.
PopulationManager surfaces both — natively bilingual, on the same Member.

One Member, three stages — the bilingual lens moving a cell.

Claims alone

E11.9

Type 2 diabetes without complications.

RAF: 0.105 (HCC 19)

→

Chart pulled

E11.9 + E11.42

+ polyneuropathy noted in clinical record.

RAF: 0.302 (HCC 18)

→

Both fused

E11.42 with chronic complications

Claims now reflect what chart already said.

RAF: 0.302 — defensible

Industry · Congress · CMS

1Industry

"CMS has data today that can show them exactly where that outlier behavior is. And it would be very simple to say, 'Let's start our auditing there.'"

Ceci Connolly

CEO, Alliance of Community Health Plans

2Congress

"UnitedHealth Group has turned risk adjustment into a major profit-centered strategy, which was not the original intent of the program."

Sen. Charles Grassley

Chairman, Senate Finance Committee

3CMS

"V28-related policy… set back the state of value-based care by a decade."

Chris Klomp

Director of Medicare & Deputy Administrator, CMS · Chief Counselor to HHS Secretary RFK Jr.

CMS · 2027 MA Proposed Rule

"Payments that accurately reflect beneficiary health risk and facilitate efficient use of healthcare resources, enhanced program integrity, and greater accountability."

CMS, 2027 MA Proposed Rule

The Cost of Unsupported Diagnoses

Billions live in the gap between what the chart says and what the claims say.

7,770

ICDs under V28 (down from 9,797).

$23.67B

MA Part C improper payments, FY 2025 — up from $19.07B FY 2024. CMS attributes the increase to Medicare Advantage Organizations' documentation failing to substantiate beneficiary diagnoses.

100%

RADV extrapolation across the full Member panel.

The data behind the doctrine

From Member Risk to Network Performance.

Three views. One Member upstream; the whole panel downstream.

Start at the Member. One row per HCC, one column per qualification year. The prior-year ✓ next to the current-year ✓ — that gap is the V28 story.

V28 in one glance · n=1 Member

HCCDescription20232024YoY
HCC 17Diabetes with chronic complications✓✓held
HCC 22Morbid obesity✓—lost
HCC 85Congestive heart failure✓✓held
HCC 96Specified heart arrhythmias—✓gained
HCC 138Chronic kidney disease, stage 4✓✓held

Drill into the same Member's ICD codes by who delivered the care. Network role surfaces where the score is captured — and where it's leaking.

HCC ICD Detail · same Member · claims by network role

HCC ICDEmployedAffiliatedPrivateOther20232024
E11.422·1·✓✓
I50.32·3··✓✓
I48.91··2·—✓
N18.411··✓✓

Pull back to the whole panel. Across all Members, two horizontal-bar views show where the score comes from — and where each network role is leaking.

The Performance and Behavior of the Clinical Network · Aggregate · all Members

Employed
62%
Largest signal contribution to plan-level RAF. Diagnostic-support depth typically strongest here — owned EHR + integrated workflows.
Affiliated
22%
Strong PCP signal, sometimes diffuse documentation depth across affiliated practices. HCC capture varies by practice maturity.
Private
11%
Diagnostic-support coverage is thinnest here. Where revenue leak shows up most clearly under V28's compressed coefficients.
Other
5%
Out-of-network and ad-hoc encounters. Least reliable HCC signal. Often dropped from network-attributed score views.

Try four Member personas

See V28 in dollar terms.

Pick a Member scenario. See V24 RAF, V28 RAF, and the annual delta.

Talk with FHG

Build V28 + RADV readiness into your operations.

Strengthen Medicare. Increase Patient Access.

Talk with FHG