Blog
InsightsJuly 28, 2026
The end of add-only HCC coding: building two-way retrospective review after a $117.7M FCA settlement
Two-way retrospective review validates every HCC a chart review touches: it submits newly supported codes and deletes previously submitted codes the...
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InsightsJuly 23, 2026
CMS-HCC V28 at 100%
Payment year 2026 is the first year every Medicare Advantage risk score is calculated entirely under CMS-HCC V28. The model maps 7,770 ICD-10-CM cod...
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InsightsJuly 21, 2026
Certified Risk Adjustment Coder (CRC)
A Certified Risk Adjustment Coder (CRC) is a credentialed professional who reviews clinical documentation and assigns ICD-10-CM diagnosis codes to s...
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InsightsJuly 16, 2026
RxHCC Risk Adjustment Model in Medicare Part D
RxHCC stands for Prescription Drug Hierarchical Condition Categories. It is the risk adjustment model CMS uses specifically for Medicare Part D — th...
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InsightsJuly 14, 2026
What Are HCC Coding Gaps
HCC coding gaps occur when a patient's chronic conditions are present in their clinical history but do not make it into the risk adjustment data sub...
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InsightsJuly 9, 2026
Medicare Advantage Rates
Every private insurer running a Medicare Advantage plan gets paid by the federal government to do it. Those payments — monthly, per member, calibrat...
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InsightsJuly 7, 2026
HCC Risk Adjustment Coding
Billing in Medicare Advantage does not work the way it does in fee-for-service. Providers do not get paid per procedure. Health plans receive a mont...
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Insights
InsightsJune 30, 2026
Prospective vs Retrospective Risk Adjustment
Health plans and provider organizations do not have a single moment to get risk adjustment right. Patient conditions need to be documented, coded, a...
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InsightsJune 25, 2026
Risk Adjustment Factor
The Risk Adjustment Factor (RAF) is a numeric score that healthcare payment systems use to estimate how much a given patient is likely to cost relat...
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InsightsJune 23, 2026
AI Risk Adjustment
Risk adjustment has always been a data problem. The model is only as accurate as the diagnoses feeding into it, and diagnoses are only as complete a...
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InsightsJune 18, 2026
AI in Medical Coding and Billing
Revenue cycle teams did not start using AI because it sounded innovative. They started using it because the volume of routine encounters outgrew wha...
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InsightsJune 17, 2026
Risk Adjustment Coding
Healthcare has never paid everyone the same rate. A patient managing diabetes, heart failure, and chronic kidney disease costs far more to cover tha...
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InsightsJune 10, 2026
Hierarchical Condition Category (HCC) Coding
HCC coding is the risk adjustment methodology CMS uses to estimate patient disease burden and calibrate reimbursement in Medicare Advantage and othe...
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InsightsApril 9, 2026
70% of AI-Generated HCC Suspects Were Rejected. Here's Why That Happens
Hierarchical Condition Category (HCC) coding is one of the areas in healthcare where AI is the obvious solution. On paper, it makes perfect sense. Use...
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