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

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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.

PASTE-IN: Snippet C · 12-Chip Strip — see “V28 — A Universal Primer · Snippet C · 12-Chip Strip (May 2026).html”

\8 codes — diagnosis in the chart, clinical evidence backs it up. Legitimate HCCs.\\4 codes — diagnosis on the bill, no clinical evidence in the 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\\

EHR · labs · meds · vitals · problem list\
\↔\</span\>\
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.”

Documented Only ⚠

“The upcoding vector · where the dollars at risk live.”

Not Documented But Supported

“The missed code · revenue left on the table.”

Neither

“No diagnosis · no evidence · no signal · 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.

PASTE-IN: Snippet D · Constellation Flow — see “V28 — A Universal Primer · Snippet D · Constellation Flow (May 2026).html”
Industry · Congress · CMS
1
Industry

“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

2
Congress

“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

3
CMS

“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
PASTE-IN: Snippet A · HCC Scorecard — see “V28 — A Universal Primer · Table HTML Snippets for Avada — A+B (May 2026).html”

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
PASTE-IN: Snippet B · HCC ICD Detail — see “V28 — A Universal Primer · Table HTML Snippets for Avada — A+B (May 2026).html”

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
PASTE-IN: Snippet E · Bar Chart — see “V28 — A Universal Primer · Snippet E · Bar Chart (May 2026).html”
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