RISE National 2026: A Turning Point for Risk Adjustment—and the Work Ahead 

This year marked the 20th anniversary of the RISE National Conference, but the milestone felt less like a retrospective and more like a clear signal of where health plan risk adjustment is heading next.

Nothing about the operating environment has gotten easier. Medicare Advantage risk adjustment programs continue to operate under sustained pressure—from rising medical and pharmacy costs to expanding audit activity and new requirements from the Centers for Medicare and Medicaid Services (CMS). At the same time, health plans are working to improve risk adjustment documentation and coding, strengthen outcomes, and maintain financial performance.

And yet, the tone at RISE felt different this year.

The challenges payers face haven’t changed—but the industry’s response to them has.

From Waiting to Taking Action

Over the past several years, many healthcare organizations approached risk adjustment programs with caution, waiting for clearer regulatory signals or more predictable guidance. But now, the executive mindset has shifted.

At RISE, it was clear that health plans are no longer waiting. Conversations focused on prospective risk adjustment implementation, with programs like targeted pilots and practical improvements to coding workflows.

Health plan leaders are asking more direct questions about Hierarchical Condition of Categories (HCC) risk adjustment coding, audit defensibility, and how to ensure accuracy across both retrospective and concurrent processes. There is growing recognition that progress comes from operational discipline, consistent improvements in risk adjustment documentation and coding rather than large, one-time transformations.

Rising Regulatory Intensity Is Reshaping Risk Adjustment

Regulatory oversight has always been a central piece of health plan risk adjustment strategies. What has changed is the scale, speed, and intensity of that oversight.

Risk Adjustment Data Validation (RADV) audits are expanding in scope and frequency, with CMS continuing to refine its methodology and apply findings more broadly across Medicare risk adjustment programs.

At the same time, enforcement bodies are aligning on common standards for validation, documentation, and submission accuracy. The U.S. Department of Justice has continued to prioritize healthcare enforcement under the False Claims Act. In addition, the Office of Inspector General has also issued ongoing guidance and reports highlighting vulnerabilities in Medicare Advantage risk adjustment.

For health plans, this means that risk adjustment payment is more closely tied than ever to critical operations like:

• Accurate clinical documentation
• Defensible risk adjustment coding
• End-to-end traceability across submission workflows

The challenge is not understanding compliance. It is keeping pace with how quickly expectations are evolving.

A More Sophisticated Threat Landscape for Health Plans

Alongside regulatory pressure, the healthcare industry is facing a more complex fraud environment.

Discussions at RISE highlighted the emergence of AI-enabled fraud patterns, ranging from synthetic documentation to coordinated submission activity that can appear clinically valid. These developments are raising new questions about how risk adjustment programs detect and prevent fraud, waste, and abuse.

The Office of Inspector General has repeatedly emphasized program integrity risks and the need for stronger oversight. Traditional approaches to risk adjustment services, often reliant on static rules or isolated reviews, are becoming less effective. Health plans are increasingly looking for solutions that combine advanced analytics with clinical validation.

Re-centering on the Purpose of the Work

Amid conversations about audits, compliance, and financial pressures, one moment at RISE stood apart. In his keynote, NBA Hall of Fame player Dominique Wilkins shared his personal journey managing diabetes and his experience competing at the highest level of his sport. He spoke about discipline, proactive self-care, and the critical role of consistent support systems.

His story served as a powerful reminder that behind every diagnosis code and risk adjustment factor is a real person, someone whose quality of care depends on healthcare organizations getting it right. Whether in Medicaid risk adjustment, commercial risk adjustment, or Medicare Advantage, the goal is the same: to accurately reflect a member’s health status so they can receive the care they truly need.

What This Means for Health Plans & How HealthEdge® is Here to Help

The direction is clear. Risk adjustment programs must continue to evolve. Health plans are moving toward more connected approaches that bring together:

• Prospective and retrospective risk adjustment workflows
• Integrated risk adjustment documentation and coding processes
• Alignment between HEDIS and risk adjustment programs
• Greater visibility across Medicaid risk adjustment and commercial risk adjustment

HealthEdge Risk Adjustment solutions were designed to help health plans address these very challenges by delivering a comprehensive approach to risk adjustment, supporting the full lifecycle, from condition identification and provider engagement to coding, submission, and reconciliation.

Our solutions enable health plans to:

• Improve accuracy in HCC risk adjustment coding
• Strengthen audit readiness with traceable workflows
• Advance prospective risk adjustment strategies
• Reduce complexity across retrospective risk adjustment
• Improve visibility into risk adjustment payment drivers

The Work Ahead

If there was one takeaway from RISE 2026, it is this: the healthcare industry has moved forward when it comes to risk adjustment.

The challenges are not new, but the urgency is greater. The expectations are higher. And the willingness to act is stronger. Leading health plans are investing in solutions, refining operations, and strengthening their risk adjustment programs to meet the demands of today’s environment.

Learn how HealthEdge Risk Adjustment solutions can help your organization. Download the white paper: Getting Risk Adjustment Right – A Guide for Modern Health Plans.