Last week, the Charta team attended RISE National in Orlando. RISE National is an annual gathering of health plan leaders, provider organizations, and representatives from the regulatory agencies that oversee Medicare programs, including the Medicare Advantage plans offered by many of the payers at the conference.
Attendees roles ranged from care delivery, clinical quality measurement, and risk adjustment to regulatory enforcement. But attendees largely share the same goal: finding new and better ways to make value-based care deliver on its promise of achieving better care coordination and patient outcomes at lower costs than traditional fee-for-service payment models.
Here’s three takeaways from the event:
1. Regulators pressed their claims
Speakers at this year’s RISE included Megan Tinker, Chief of Staff at the HHS OIG office; Edward Crooke of the DOJ’s Civil Division; and Arjuna Swaminathan, OIG’s Chief Artificial Intelligence Officer.
All three emphasized the government’s intention to flex its regulatory and enforcement powers to bring costs down for consumers. Scrutiny of Medicare Advantage has never been higher. And as Swaminathan explained in detail, the government now has the benefit of AI technologies to aid in its detection of fraud and abuse.
The message these watchdogs sought to convey was clear: regulators and law enforcement agencies believe that it’s past time to rein in the behaviors that have led to higher costs, such as diagnosis code submissions derived from unlinked chart review records, and the related (and potentially widespread) practice of failing to delete historical HCC codes for conditions that are no longer actively being assessed and managed.
2. RADV readiness is no longer optional
CMS is moving toward universal RADV reviews.
In practical terms, this means every MA plan should be operating as if a RADV audit is already underway. Documentation must support every submitted diagnosis, coding practices have to be ready to withstand scrutiny, and plans require processes and technologies for identifying and closing compliance gaps before they become audit findings.
Plans investing in new technology for RAF accuracy and RADV readiness aren't just protecting themselves from potential sanctions: They're building a more accurate understanding of patient acuity, which is the whole point of HCC coding to begin with.
3. VBC is experiencing some growing pains
Recent government studies suggest that Medicare Advantage is now more costly than traditional fee-for-service Medicare. Meanwhile, large plans are deliberately shedding MA members by exiting less profitable markets. As plans pull back, millions of MA members face potential disenrollment.
The trends are related: The enforcement actions and regulatory tightening that prompted the pullbacks have occurred in response to the rising costs of the Medicare Advantage program. Regulators and lawmakers (and increasingly, the general public) view the surging costs as resulting from manipulations by payer organizations that are trying to game the system. An observer viewing these trends in isolation could be forgiven for assuming that we’re seeing a reversal of the trend toward value-based care and a move back in the direction of fee-for-service models.
But value-based care has been through these cycles before: VBC generates optimism, runs into the messy reality of healthcare economics in the U.S., absorbs a wave of skepticism, and then finds a more mature footing. Attendees I spoke with, including two longtime veterans of the RISE circuit, believe we're in one of those low moments. The market contractions are real, and the plans exiting "risky" geographies are making rational financial decisions. But the infrastructure that arose to support VBC—around documentation, outcomes measurement, and care coordination—still matters. And the point of the enforcement actions isn’t to end VBC: it’s to get the system back on track to bringing down healthcare costs for Americans.
Looking forward
The plans that will navigate this environment are the ones treating compliance and RAF accuracy as one integrated effort, not a siloed legal risk mitigation strategy working in tension against a revenue optimization strategy. As regulators deploy new and better AI to find fraud, plans that use AI to ensure accuracy are building exactly the right kind of defense.