In Q4, Medicare Advantage risk adjustment leaders are balancing two critical priorities: closing out the current year successfully and preparing for the year ahead. In our previous blog, Closing the year strong: Medicare Advantage risk adjustment priorities for Q4 2026, we explored key actions plans can take to optimize current-year performance. Here, we shift focus to the future, examining the policy changes, audit expectations, technology considerations, and operational strategies that can help organizations build a stronger, more resilient risk adjustment program for 2027 and beyond.
Even as teams are heads-down on current-year execution, policy, audit, and technology developments are converging in ways that will define how MA coding and submission programs need to operate going forward. Several of these developments are already affecting 2026 decisions.
Audit readiness can no longer be approached as a periodic exercise.
CMS is transforming Risk Adjustment Data Validation (RADV) from a selective audit activity into a much broader program-integrity expectation. In May 2025, CMS announced that all eligible MA contracts would be included in newly initiated audits for each payment year. Recent enforcement has also focused not only on unsupported diagnoses that were submitted, but on whether organizations identified and withdrew inaccurate diagnoses.
In this environment, risk adjustment programs need processes that support both sides of coding accuracy: identifying and validating clinically supported diagnoses while correcting or withdrawing diagnoses that are not supported. Each diagnosis used for payment should be traceable to an acceptable medical record, qualifying encounter, provider type, date of service, and applicable coding guidance.
Organizations must move beyond reactive audit preparation and toward continuous audit readiness. Dedicated workflows for structured validation, correction, and deletion, supported by independent second-level review of selected high-risk diagnoses and first-pass coding results, can strengthen compliance, improve documentation integrity, and maintain an auditable record of risk adjustment activity year-round..
Automation can help prioritize records, identify anomalies, and direct limited coding resources, but its governance is becoming as important as its efficiency. OIG's 2026 MA compliance guidance identifies risk involving prompts, including prompts generated by artificial intelligence, that encourage unsupported diagnoses or diagnoses that did not affect the member's care, treatment, or management.
OIG recommends oversight of queries and prompts, software used by plans and providers, vendor activities, data-filtering logic, and diagnosis data both before and after submission. Practical controls include approved use cases, documented clinical and coding logic, appropriate human review, versioned audit trails, vendor monitoring, exception testing, and defined escalation and correction workflows. Automation may accelerate work; disciplined governance makes the output explainable, reproducible, and defensible.
CY 2027 makes encounter linkage an immediate priority.
In the CY 2027 Rate Announcement, CMS finalized a payment policy excluding diagnoses from unlinked chart review records (CRRs) from risk-score calculations, with a limited exception for beneficiaries who switch from one MA parent organization to another. Because CY 2027 risk scores are based on diagnoses from CY 2026 dates of service, this is a current operational issue, not a future-year planning exercise. MA organizations may still submit unlinked CRRs, but the diagnoses generally will not count toward CY 2027 risk scores. The impact will vary according to each organization's reliance on unlinked records and its ability to connect clinically supported diagnoses to encounter data.
CMS will continue using the fully implemented 2024 CMS-HCC model, commonly called V28, for CY 2027 and will exclude diagnoses from audio-only encounters for non-PACE organizations. At the same time, the FY 2027 ICD-10-CM code set takes effect October 1, 2026. That boundary places two code sets within the same MA risk-adjustment data year, so the same condition may be reported differently for dates of service before and after October 1. Plans should review the official addendum and final coding guidelines when available, assess whether relevant changes affect HCC mapping, update technology and EHR workflows, and prepare coders and providers. Code changes do not automatically change HCC assignments, but outdated or mismatched codes may trigger edits, rejections, or reconciliation issues.
In an encounter-linked environment, coordinated engagement helps create clinically appropriate opportunities for providers to evaluate conditions during qualifying encounters and document them when appropriate.
The most effective outreach strategies start well before deadlines approach. Ongoing visibility into performance, emerging gaps, and member and provider needs allows organizations to prioritize opportunities and act when intervention can have the greatest impact. Timely, regularly refreshed reporting and forecasting help teams move beyond reactive outreach and make more informed decisions throughout the year.
Equally important is ensuring engagement efforts are coordinated. When outreach is driven by disconnected programs or separate target lists, providers and members can receive multiple requests that create confusion and fatigue. By integrating risk and quality insights and outreach, organizations can gain a more complete view of opportunities, coordinate clinically appropriate actions, and measure whether engagement contributes to downstream outcomes. The result is not only a better experience for providers and members, but also a more effective path toward accurate risk and quality performance.
As coding requirements evolve and audit scrutiny increases, MA organizations that invest in encounter-linked documentation, integrated workflows, governed automation, two-way coding controls, and continuous audit readiness will be better positioned to adapt. These capabilities can help plans improve risk-score accuracy and revenue integrity while maintaining the evidence and oversight required for audit defensibility.
By acting now, risk adjustment leaders can move beyond reacting to deadlines and build programs prepared to deliver accurate, supportable results under both today's requirements and tomorrow's expectations.
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