v28 + RADV

Program Integrity is every plan’s job. Build it from the inside.

U.S. health care is structurally blind.
Forward Health Group reads both sides — one Member at a time.

The FHG answer to V28

Clinical and Claims, Fused. Natively Bilingual.

Most v28 tools speak one language. Forward Health Group speaks two — natively, on the same Member, in the same view. The chart shows what the clinician saw. The claims show how the system actually moved.

Rolling 12-month Measurement (Year-over-Year)
X-axis: Change in Patient Visit Volume
Y-axis: Change in TOSH (Time Outside Scheduled Hours)

Overview

See, by Member, which conditions qualified last year and which qualify this year — the v28 story in one row.

Quantify v28’s compression on raw and normalized RAF, with Member-level traceability back to the qualifying ICDs.

See, by Member, which conditions qualified last year and which qualify this year — the v28 story in one row.

Separate Employed, Affiliated, Private, and Other claim activity to see where score is being captured — and where it’s leaking.

Surface the gap between Members on a PCP’s panel and Members whose claim activity actually flows through that PCP.

Separate Employed, Affiliated, Private, and Other claim activity to see where score is being captured — and where it’s leaking.

Every score contribution backed to the specific ICD codes that produced it — auditable on demand.

Focus diagnostic-support work where the math actually moves — before the auditors arrive.

Roll-ups for the C-suite; scorecards for the panel; one connected

Note: TOSH (Time Outside Scheduled Hours)

“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

Forward Health Group makes Program Integrity operational, one Member at a time.

V28 IN ONE GLANCE · N=1 MEMBER → HCC SCORECARD TABLE

HCC Description Score ICDs 2025 QUAL 2026 QUAL
HCC85 Congestive Heart Failure ·.··· I50.xx ✓ ✓
HCC18 Diabetes with Chronic Complications 0.000 E11.xx ✓ —
HCC111 Chronic Obstructive Pulmonary Disease ·.··· J44.x ✓ ✓
HCC108 Vascular Disease ·.··· I70.x — ✓
HCC55 Substance Use Disorder ·.··· F11.xx ✓ ✓

Schematic. Faux Member, FHG-internal demo only.

HCC ICD DETAIL · SAME MEMBER · CLAIMS BY NETWORK ROLE → ICD DETAIL TABLE

HCC ICD EMPLOYED AFFILIATED PRIVATE OTHER HCC Value Score
I50.20 1 2 0 0 HCC85 0.331
E11.36 0 0 0 1 HCC18 0.000
J44.9 1 3 0 0 HCC111 0.335
I70.0 2 0 0 0 HCC108 0.288
F11.20 0 1 1 0 HCC55 0.329

Schematic. Faux Member, FHG-internal demo only.

THE PERFORMANCE AND BEHAVIOR OF THE CLINICAL NETWORK · AGGREGATE · ALL MEMBERS

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

“We do not want risk adjustment to be a source of competitive advantage for health plans.”

Chris Klomp,
Director of Medicare & Deputy Administrator, CMS

7,770

ICDs under v28
(down from 9,797).

$12.7B

MA overpayments — unsupported diagnoses (HHS OIG).

100%

RADV extrapolation across full Member panel.