Risk Adjustment Made Scalable: How Veradigm CORE Delivers
Written by: Lesley Weir, Senior Director, Solutions Strategy, Veradigm, and Cheryl Reifsnyder, PhD
Healthcare payers are navigating a rapidly changing environment marked by regulatory updates, evolving quality incentives, and heightened audit scrutiny. Policy reforms and interoperability mandates are accelerating the shift towards value-based care, requiring payers and providers to align on risk adjustment, quality and efficiency goals. At the same time, CMS has adopted more aggressive audit strategies, signaling plans to expand Risk Adjustment Data Validation (RADV) reviews to an annual cadence starting with payment year 2025 .
Medicare Advantage (MA) continues to grow, with about 54% of eligible beneficiaries enrolled in MA plans in 2025, driving substantial federal spending and increasing the stakes for accurate risk adjustment and quality performance. At the same time, payers face rising costs, evolving quality standards, and mounting regulatory pressures. These trends are fueling demand for prospective care management and risk adjustment, both critical for closing care gaps, managing risk, and improving outcomes.
Quality programs like Star Ratings continue to influence plan revenue and benefits, with 2026 ratings appearing on Medicare Plan Finder and flowing into 2027 bonus payments. These changes underscore a critical shift: Payers and providers must embrace prospective care management and risk adjustment to stay ahead.
First, let’s examine the key challenges in risk adjustment and quality care, then see how Veradigm’s Comprehensive Outcomes Realization and Engagement program (CORE) addresses each with end-to-end integration.
The technical hurdles plans and providers face
These challenges often stem from missed or delayed care gap closure, which impacts both risk scores and quality ratings.
1. The HCC model is changing, again
CMS finalized Version 28 of the CMS‑Hierarchical Condition Category (HCC) model and phased it in over three years. The update shifts condition groupings and code mappings and is now fully applied to 2025 dates of service.
2. Hidden diagnoses create silent risk adjustment factor loss
Payments depend on diagnoses supported in the medical record. CMS’s RADV framework requires submitted diagnoses to be backed by documentation. The Office of the Inspector General estimated $7.5 billion in 2023 payments were tied to diagnoses reported only in Health Risk Assessments (HRAs) or HRA-linked chart reviews without other service records.
3. Quality gap closure drives Star Ratings
The Healthcare Effectiveness Data and Information Set (HEDIS) is one of the most widely used toolsets for measuring plan performance, covering 90+ measures across domains like effectiveness of care, access, and utilization, and underpinning reporting tied to Stars. CMS rates MA‑PD contracts on dozens of measures.
4. Audit readiness is no longer a back‑office task
CMS finalized its RADV methodology in 2023, allowing extrapolation beginning with payment year (PY) 2018 and eliminating the Fee‑for‑Service adjuster. That heightens exposure if submitted diagnoses aren’t supported in the chart. The stakes are rising even further: CMS announced in May that 100% of plans would be audited annually beginning with PY 2025. However, Judge Reed O’Connor of the U.S. District Court for the Northern District of Texas on September 25. 2025 vacated and remanded the 2023 final rule, which means means the rule is nullified and no longer in effect. This is not the end of RADV audits, it is merely a pause until CMS resolves the Administrative Procedure Act of 1946 (APA) violations. Every organization must assume it will be audited and prepare accordingly. Plans and providers need documentation that stands up to scrutiny and a clean path from encounter to submission to reconciliation.
Veradigm CORE– Veradigm CORE is a purpose-built solution designed for today’s rapidly evolving healthcare environment.
It brings together advanced technology and clinical services—seamlessly integrated with Veradigm-owned and partner EHRs—to help providers and payers:
- Identify and prioritize care gaps
- Close gaps in quality and risk adjustment
- Ensure accurate documentation of clinical and coding data
By embedding these capabilities into everyday workflows, CORE empowers care teams to improve performance on key measures, drive better patient outcomes, and elevate Medicare Star Ratings.
It’s delivered by payers to support their providers and designed for provider workflows to reach a large network of independent practices.
Prospective identification that matters
- Patented algorithms identify conditions that require recapture, suspected conditions, and open care gaps tied to risk and quality measures before a face-to-face provider visit. Opportunities are ranked by confidence level and potential impact.
- Pre‑visit chart preparation packages the relevant history, prior diagnosis codes, medications, lab results, and open preventative screening items so care teams can address them during the visit.
- At the point of care, bidirectional EHR integration delivers targeted prompts. Providers see exactly which documentation elements are needed to support a diagnosis this year, reducing rework later.
Documentation and coding that fit the encounter
- Clinical documentation templates guide history, exam, and assessment details for common HCC conditions, right in the EHR.
- Post‑visit coding workflows queue charts for review when needed. Coding specialists confirm ICD‑10 selection and link each condition to the encounter note.
- If a suspected condition isn’t confirmed, the workflow moves on. If it’s confirmed, the note contains supporting documentation for the diagnosis code and the diagnosis posts for risk capture.
Quality gap closure without piling on provider clicks
- Quality prompts focus on measures tied to Stars and HEDIS, including screenings and tests that extend beyond already scheduled visits when plans opt into services.
- Provider education and job aids give teams quick reminders on measure specifics so they can act during routine care.
Submission and audit readiness built in
- Veradigm specialists review face-to-face encounters and work directly with providers to fix omissions, building an audit trail that supports RADV readiness.
- Pay‑for‑performance pricing keeps attention on closed gaps and coded, documented outcomes.
At scale, where it matters
- CORE is built to reach independent ambulatory practices through bidirectional EHR integration. Veradigm’s 300,000+ provider footprint is particularly well-suited to focus on independent practices that often lack extra staff for value‑based tasks.
Why clinical and coding integration changes results
Disjointed tools create orphaned care gap lists and partial documentation. When clinical workflows, coding review, and submissions run as one process:
-
Risk capture becomes a more accurate reflection of each patient’s true health status. Teams address suspected conditions during face-to-face patient visits. Diagnoses are recorded with the exam, assessment, and plan in the same note. That supports accurate payments under the HCC model in a way that aligns with CMS documentation expectations.
-
Quality performance improves with fewer fire drills. HEDIS measures are displayed to the provider at the right time, which supports Star Ratings and reduces end‑of‑year chases and supplemental requests.
-
Audit exposure comes down. Encounter‑level documentation, coding review, and clean submissions reduce the gap between what’s billed and what’s supported. That matters under an audit approach that allows extrapolation back to PY 2018.
Making the shift to prospective risk adjustment and quality improvement
Risk adjustment and Stars aren’t separate problems. They meet in the exam room and in the notes. Veradigm CORE ties the work together with algorithms, templates, and workflows that live in the EHR, backed by services that help close the loop from identification to documentation to submission. That’s how payers, accountable care organizations, and other healthcare organizations can keep up with HCC changes, close quality gaps, surface hidden diagnoses in the provider’s workflow, and be ready for audits, all while keeping clinic time focused on patient care.
Experience how Veradigm CORE can optimize your risk-adjustment strategy and safeguard revenue. Schedule your personalized demo today.