You Already Have a Vendor for That
Every function in a health plan is covered by a vendor. No one is accountable for the member. Ro Bhardwaj on why plans cannot answer basic questions about their own operations.
Quality Wrote Your Retrieval Spec, and Risk Adjustment Is Paying for It
Quality abstraction stops when the measure is satisfied. Risk review needs the whole record. When a plan merges its chart chase, one stopping rule survives and recapture pays for it a year later.
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 Cost Per Closed Gap: How to Calculate It
Prospective, retrospective, and in-home programs are compared on RAF yield. Cost per accepted capture is the number that compares them honestly.
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.
Explainable AI in Risk Adjustment: How to Test the Claim
Every AI coding vendor says explainable. The only definition that settles anything is the one an auditor uses. How to test the claim in a demo.
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.
Coder Rework: Paying Twice to Code the Same Conditions
Conditions that were confirmed and submitted but never counted come back as fresh suspects. How to measure what your coders are working twice.
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.
