Chronic disease is not a new problem in Medicare — but it is a problem that is persistent, expensive, and stubbornly resistant to the payment structures designed around it. More than two-thirds of Medicare beneficiaries live with at least one chronic condition.

When the Centers for Medicare & Medicaid Services(CMS) released its January 26 Medicare Advantage Proposed Rule 2027, most attention went straight to the rates. That reaction was predictable. Payment updates influence bids, margins, and near-term strategy across organizations participating in Medicare Advantage.

In early spring, the Medicare Advantage CMS Advance Notice 2027 (the CMS Advance Notice) outlines proposed payment updates for the upcoming plan year — including adjustments to risk models, normalization factors, benchmarks, and Star Ratings methodology.

As part of our series “How To Effectively Leverage Data To Take Your Company To The Next Level,” I had the pleasure of interviewing Dr. Arun Hampapur. Founder and CEO of Bloom Value Corporation (a technology…

Defensible risk adjustment ensures every Medicare Advantage code is clinically justified, transparent, and traceable, reducing audit, financial, and reputational risks....

The investigation has triggered bipartisan concern, with lawmakers scrutinizing whether risk adjustment practices have crossed ethical lines. The move signals a shift from passive oversight to active enforcement, putting the future of MA funding and the industry's credibility at a tipping point.

For healthcare providers, prior authorization represents an additional layer of administrative complexity. They must familiarize themselves with specific requirements, gather supporting documentation,…

Medicare Advantage Organizations (MAOs) - including health plans, IPAs, MSOs, and risk-bearing providers are grappling with a wave of unprecedented challenges. The implementation of CMS’s Hierarchical Condition Category (HCC) risk adjustment model Version 28 (V28) is already reshaping the industry.