The Biggest Risk in Payer Operations Is the Space Between Your Systems
Risk, coding, encounters and quality do not talk to each other, and CMS now prices that gap. Rohit Bhardwaj on what plans should build instead.
Risk Adjustment ROI: What the Vendor Ratio Leaves Out
A quoted risk adjustment ROI describes a vendor’s client list, not their platform. Here is where the return actually separates, and why it matters.
2026 ACA Risk Adjustment Model: What Changed
A cell by cell read of the 2026 ACA risk adjustment model: a new PrEP cost factor, 320 coefficients moved, and why the 77-code number is widely misread.
Costco, SCAN, and the Coming Fight Over Medicare Advantage Member Data
Everyone read the Costco and SCAN deal as distribution. The next round of retail partnerships will be negotiated over Medicare Advantage member data.
Top 20 MA Plan Selects Invent Health for AI Risk Adjustment Coding
A top 20 Medicare Advantage plan has selected Invent Health and gone live on Coder Workbench 2.0. AI-assisted risk adjustment coding that runs natively inside the electronic health record.
Immunization Care Gaps: 3 Leaks Costing Plans Stars
Why do vaccinated members still show as immunization care gaps? The three data leaks that cost plans Stars revenue, and how to find yours by year-end.
Encounter Submissions: Can You Prove Every Coded Diagnosis Reached CMS?
Most plans cannot prove every coded diagnosis reached CMS. Invent Health’s CEO announces Encounter Submissions, the closed loop that ends the guessing.
Behavioral Health: Why Your Risk Scores Keep Missing It (and Who Pays for It)
Behavioral health is the diagnosis your risk model keeps missing, and it hits underserved members hardest. See why it happens and how plans fix it under V28.
He Won’t Go to the Doctor…So How Does Your Plan Know He’s Sick?
Many male members delay preventive care, creating documentation gaps and hidden risk. Learn how prospective risk adjustment strategies can help health plans identify and manage risk earlier.
How NLP Improves HCC Capture Accuracy
See how NLP lifts HCC capture accuracy by surfacing evidence, keeping a coder in the loop, and measuring capture where it pays: CMS acceptance.
