Introduction

For Medicare Advantage (MA) health plans and other risk-bearing organizations, accurate risk adjustment is essential to ensuring that compensation is aligned with the true health needs of your population. The accuracy of 2025 risk adjustment submissions will directly influence capitation payments and your focus on population health management.
As we enter the final quarter of 2025, now is the time to ensure you have a complete and accurate picture of your membership’s health risk, positioning your organization for success in the year ahead. While not your organization’s last bite at the risk adjustment apple, the more you do now, the better you are positioned.

Core Year-End Priorities

With CMS deadlines approaching, the fourth quarter is an important moment to double down on ensuring that appropriate coding, documentation, and data integrity processes are optimized to inform opportunities to improve patient engagement and implement clinical best practices.

To maximize financial accuracy and regulatory compliance, organizations should focus on the following year-end activities:

• Chart Reviews & Diagnosis Validation:
  Review medical records to confirm chronic conditions are properly documented and coded. This reduces missed HCCs and minimizes audit risk.
• Provider Outreach:
  Engage with providers to address documentation gaps, encourage annual wellness visits, and reinforce the diagnostic coding requirements for HCCs.
• Data Reconciliation:
  Cross-check encounters, claims, and EHR entries to ensure that all diagnosis codes are captured and submitted appropriately.
• HCC Submission Audits:
  Verify that HCCs identified throughout the year are submitted and accepted in the Risk Adjustment Processing System (RAPS) and Encounter Data System (EDS) before CMS deadlines. Late submissions won’t count toward risk scores.

Risk Adjustment Best Practices

Organizations can strengthen risk adjustment activities by implementing best practices focused on accurate and comprehensive documentation. Additionally, these best practices will further enhance quality performance, helping to identify open care gaps that influence HEDIS measures and Star Ratings, further supporting both financial performance and patient outcomes.

• Accurate & Specific Coding: Capture all active chronic diagnoses, using precise ICD-10 descriptions aligned with the current CMS-HCC model.
• Annual Wellness Visits: Ensure patients are seen annually, with active conditions documented appropriately for inclusion in following year’s payment.
• Year-End “Sweep” Processes: Conduct a final reconciliation of all records to maximize the completeness of submissions and mitigate risk of lost revenue due to missing codes.

How COPE Health Solutions Can Help

End-of-year risk adjustment is about ensuring your organization is compensated fairly for the care you deliver and equipped with the necessary information to improve patient outcomes in the year ahead. It’s also about making sure your organization has access to the best data to inform your population health management programs., thus creating a win-win for your organization and patients going into 2026.

Together with your organization, COPE Health Solutions can improve clinical documentation to identify gaps and enhance coding accuracy, leading to improved patient interactions and outcomes. Analytics for Risk Contracting (ARC), our market-leading population health management platform, can support the identification of missing, suspected, and expiring HCCs and drive measurable improvements in quality gap closure.

If your organization needs support – COPE Health Solutions will get you back on track.

To learn more about how COPE Health Solutions and ARC can help position your organization for success, contact us at info@copehealthsolutions.com.