RISE National 2026 brought together health plan leaders, policymakers, and industry partners to examine how Medicare Advantage is evolving in the face of rising costs, regulatory scrutiny, and growing expectations for better outcomes. From risk adjustment and data integration to AI and compliance, the conference underscored a shared priority across both payers and providers: turning accurate data into better decisions and better care. Here are five key themes emerging from RISE that are expected to play a pivotal role in health plan operations in 2026 and 2027.
The evolving role of risk adjustment
One of the most consistent themes at RISE was the critical role health plans play in improving care delivery and the opportunity to evolve how risk adjustment supports that goal. Across multiple sessions, speakers emphasized that risk adjustment data should do more than inform payment; it can help provide additional visibility into member health needs and support care coordination activities. This shift is accelerating the need for plans to move “left,” leveraging risk adjustment insights earlier in the care continuum to drive both clinical and financial outcomes.
During the CMS Innovation Center keynote, Director Abe Sutton described Medicare Advantage as being at a pivotal moment. With healthcare costs widely viewed as unsustainable, the industry is increasingly focused on affordability through accountable care, evidence‑based prevention, and competition within the MA market. Risk adjustment remains foundational in this effort.
While the full implementation of the V28 model represents significant progress, RISE highlighted the need to revisit how risk adjustment data connects to care delivery. The next phase of innovation requires aligning risk data more closely with clinical workflows so that it supports better care coordination and population health efforts.
Compliance and AI governance as strategic advantages
Compliance also took center stage at RISE, including during the session led by Megan Tinker, Chief of Staff in the Office of Inspector General (OIG) at the U.S. Department of Health and Human Services. Her session reinforced the core promise of Medicare Advantage: delivering better care and better value for patients. To uphold that promise, the OIG is expanding oversight across access to care, financial stewardship, and data accuracy. As health plans adopt more advanced AI capabilities, speakers emphasized the need to pair data‑driven decisions with human judgment.
Risk adjustment remains a key compliance focus. For FY 2025, CMS estimated the Medicare Advantage improper payment rate at 6.09%, or $23.67 billion, also due to documentation that does not adequately support submitted diagnoses.
Approaches outlined by the OIG include expanded audits, targeted evaluations of conditions with high error rates leveraging resources such as the dedicated toolkit, encouragement of self‑auditing, and education for both plans and providers. Speakers also stressed the importance of conducting due diligence with third‑party vendors to help support compliance objectives. Throughout these discussions, one principle remained clear: accurate diagnosis data is essential not only for compliance, but for enabling better care for patients.
AI as a catalyst for efficiency and insight
AI and advanced analytics were central to conversations at RISE National, with speakers describing them as revolutionary tools with the potential to improve efficiency and help contain costs. Panelists highlighted AI’s ability to make healthcare more accessible and affordable when applied safely and responsibly. However, alongside opportunity, regulators are increasingly focused on the risks of AI misuse. Recent enforcement actions highlight how AI can be leveraged to generate unsupported diagnoses or facilitate fraudulent enrollment practices when not properly governed.
Key areas of opportunity include overcoming data fragmentation, and improving data quality and completeness. AI can help support operations through assistive capabilities such as diagnosis capture and clinical documentation support, while also augmenting care delivery by supporting clinicians as they manage increasing volumes of medical knowledge.
Throughout these discussions, a consistent message emerged: AI works best with humans in the loop. Technology can scale insight and efficiency, but clinical judgment and oversight remain essential. Health plans were encouraged to act soon, recognizing that rapid change creates both urgency and opportunity.
Integrating data to enable early intervention and better experiences
Another major theme from RISE was the need to integrate data across departments and with providers to improve efficiency and create a more complete view of the member. Fragmented systems and siloed workflows continue to slow decision‑making and limit the value of otherwise rich data.
By integrating data and sharing intelligence across the organization, health plans can build a holistic member view that supports both operational efficiency and better experiences for members and providers. Technology platforms that connect to and enhance existing workflows play a critical role in this effort. The result is real‑time, actionable insight that enables earlier intervention. When plans can identify needs sooner and act with confidence, they can be better positioned to improve outcomes while reducing administrative burden. This shift is also driving increased interest in intelligence platform-based approaches that unify data, analytics, and workflows, reducing fragmentation and enabling enterprise-wide decision-making.
Delivering trusted data for actionable intelligence
Cotiviti’s own session at RISE reinforced how improving data liquidity can support value-based program performance. Accelerating time to data was a critical theme. By synthesizing data from multiple sources into insights that are actionable, validated, and auditable, health plans can act faster and with greater confidence. This approach also enables the development of longitudinal intelligence that supports continuous engagement and informed decision‑making.
The session acknowledged ongoing challenges, including data quality and the need for shared context across organizations. Strong AI governance emerged as essential, with examples of best practices including cross‑department AI committees, guardrails, built‑in audit trails, data integrity and bias monitoring, and continued human‑in‑the‑loop oversight.
Looking ahead as 2027 rapidly approaches
RISE National 2026 highlighted an industry in transformation, where success depends on aligning innovation with accountability and outcomes. Advancing risk adjustment, integrating data, adopting AI responsibly, and strengthening compliance programs are not isolated efforts—they are interconnected priorities that shape the future of Medicare Advantage.
Webinar series: 2026 Risk Adjustment Essentials
Stay on top of the latest risk adjustment trends and insights with Cotiviti’s Risk Adjustment Essentials webinar series. Attend our webinars as we walk through:
- Adopting best practices for payers and providers throughout the year
- Navigating key regulatory updates, including the CMS Medicare Advantage Advance Notice and Final Rule
- Future-proofing compliance and driving audit readiness
