Healthcare organizations preparing for 2027 face a familiar challenge: keeping up with Medicare Advantage risk adjustment changes while ensuring documentation, coding, and data-submission processes remain accurate.
But what happens when a significant proposed change is not finalized?
Organizations may spend time preparing for a new risk adjustment model that CMS ultimately decides not to implement, while overlooking changes that will affect which diagnoses contribute to risk scores.
For 2027, understanding that distinction is essential.
The 2024 CMS-HCC model remains in place.
In its CY 2027 Medicare Advantage Advance Notice, CMS proposed recalibrating the risk adjustment model using more recent diagnosis and expenditure data.
However, the final CY 2027 Rate Announcement confirmed that CMS will continue using the 2024 CMS-Hierarchical Condition Categories (CMS-HCC) model, commonly referred to as Version 28 (V28), which was fully implemented in 2026.
Organizations do not need to prepare for the proposed recalibrated model. However, updated normalization factors and diagnosis eligibility requirements still warrant attention.
Audio-only diagnoses will be excluded.
Beginning in CY 2027, CMS will exclude diagnoses from audio-only encounters when calculating Medicare Advantage risk scores.
This distinction matters because a telehealth service may be appropriate and separately reimbursable without its associated diagnoses necessarily qualifying for risk adjustment.
Organizations should review how telehealth encounters are identified and how eligible diagnoses are captured and submitted.
Unlinked chart review records face new restrictions.
CMS also finalized the exclusion of diagnoses submitted through unlinked chart review records (CRRs) from risk score calculations.
An exception applies to qualifying beneficiaries who switch between Medicare Advantage organizations from one year to the next.
For organizations using chart review processes, this change reinforces the importance of understanding how diagnosis information is associated with encounters and submitted for risk adjustment.
What should organizations prioritize?
Rather than preparing for an entirely new CMS-HCC model, organizations should focus on accurate diagnosis documentation, appropriate code assignment, encounter eligibility, and reliable data-submission processes.
A diagnosis may be clinically supported and correctly coded but still fail to qualify for risk adjustment because of how the encounter or diagnosis information was submitted.
As organizations prepare for 2027, reviewing these processes can help identify potential gaps before they become recurring concerns.
BCA, Inc. supports healthcare organizations through auditing, targeted education, and consulting to evaluate risk adjustment documentation, identify coding and submission-related vulnerabilities, and strengthen internal processes.
Preparing for 2027 is not about implementing every proposed change. It is about understanding what CMS finalized and ensuring your organization’s practices align with those requirements.
Book your consultation today with one of our experts.