HCC Risk Adjustment Software Compared: 11 Tools for Health Plans and ACOs (2026)

By Gautamdev Chowdary, co-founder and CTO, Zynix AI · Updated November 6, 2026

Disclosure: Zynix AI makes one of the platforms in this guide. Every description of another vendor comes from that vendor’s own website as of November 6, 2026, linked in the source notes. This is not a ranking: products change, so confirm current capabilities with each vendor.

Key takeaways

HCC risk adjustment software helps health plans, ACOs and provider groups document chronic conditions accurately so that CMS-HCC risk scores reflect how sick their patients really are. Tools differ mainly in when they work: before the visit (prospective), during or right after it (concurrent), or on charts after the fact (retrospective).

• Since payment year 2026, CMS calculates Medicare Advantage risk scores entirely with the 2024 CMS-HCC model (commonly called V28), so every tool should support it.
• Retrospective chart-review platforms include RAAPID, Reveleer, Cotiviti and Optum; point-of-care tools include ForeSee Medical, Navina, Vatica and Lightbeam’s Provider Compass; Arcadia and Innovaccer offer risk adjustment inside wider value-based care platforms.
• Several vendors sell software, coding services or both, so decide who will do the coding before you compare features.
• Zynix AI is not a coding tool: it ranks open HCC gaps, prepares clinicians before visits and gets patients with no visit booked onto the schedule, while clinicians make every diagnosis.

What does risk adjustment software do?

CMS pays Medicare Advantage plans, and adjusts ACO benchmarks, using risk scores built from documented diagnoses mapped to hierarchical condition categories (HCCs). A diagnosis counts only when a clinician documents it from a face-to-face encounter and the record supports it. Risk adjustment software finds conditions that are likely present but undocumented, puts the evidence in front of clinicians or coders, and checks that what is submitted is supported, which is what risk adjustment data validation (RADV) audits test.

Most products combine some of four jobs:

• Prospective (before the visit): suspect lists and pre-visit chart prep so the clinician can evaluate likely conditions during the encounter.
• Concurrent (during or right after the visit): point-of-care prompts in the EHR, or a check of the claim before it is billed.
• Retrospective (after the visit): chart retrieval and NLP-assisted coding review to add missed diagnoses and remove unsupported ones.
• Audit readiness: evidence trails and RADV preparation.

The 2024 CMS-HCC model (V28) is now fully in effect

CMS phased in the 2024 CMS-HCC model over three years. Its CY 2024 Rate Announcement set the blend at 67% of the old 2020 model and 33% of the 2024 model for 2024, then 33% and 67% for 2025, and 100% of the 2024 model for 2026. In its CY 2026 Rate Announcement, CMS confirmed it is “calculating 100% of the risk scores using only the 2024 CMS-HCC model.” For what changed between the models, see HCC V28 changes explained.

Risk adjustment software at a glance

Each row summarizes the vendor’s own description as of November 6, 2026. “Where it works” uses the vendor’s own terms. The last column is our reading of who each may suit, not a ranking.

The vendors, one by one

ForeSee Medical

ForeSee Medical’s ESP platform supports “Prospective Coding,” “Retrospective Coding” and hybrid workflows that combine them. It presents risk adjustment suspects “on your EHR screen at the point of care along with HCC coding recommendations,” uses AI and NLP to find missed conditions and validate documentation, and offers a V24 to V28 Optimizer for the model transition. It is sold as software for the customer’s own providers and coders, and serves MA plans, ACOs, IPAs, provider networks and coders.

Optum risk adjustment

The episource.com domain now redirects to Optum’s risk adjustment page. Optum pairs services with software: Optum Prospective Solutions and an in-office assessment program, where “AI-enabled analytics help providers identify suspect conditions and quality gaps before appointments,” a full-service retrospective program that uses AI to target charts, and Optum Risk Analytics, where users “can run prospective, concurrent, and retrospective campaigns.” It describes itself as serving health plans and provider organizations.

RAAPID

RAAPID, founded in 2022 and based in Louisville, Kentucky, builds a “Neuro-Symbolic AI” platform for retrospective, prospective and RADV audit work. Its retrospective product offers “two-way coding that adds missed diagnoses and removes unsupported ones, with MEAT evidence for every HCC,” sold as full service with its certified coders, software only, or as an integration. On the prospective side, “the physician confirms or rejects with a reason. Nothing is coded without a face-to-face encounter.” It launched a RADV Audit Solution in August 2025.

Reveleer

Reveleer, headquartered in Glendale, California, covers retrospective risk adjustment, prospective risk adjustment (“CDI pre-visit review, point-of-care insights, and post-visit pre-bill checks”) and RADV audits, with full-service, software-only or hybrid models. In its retrospective product, its EVE AI recommends codes with the chart excerpt behind each, and “a coder confirms each code.” In January 2026 it announced EVE Hybrid AI, which pairs generative AI evidence extraction with clinician-authored rules. It says it supports CMS V28 and HHS V08 and integrates with Epic and athenahealth.

Vatica Health

Vatica Health, founded in 2011, says it has merged with Cozeva. Its model is prospective and centered on primary care: “Vatica licensed nurses and admin support are assigned to practices,” certified auditors review codes and documentation after the visit, and Vatica Connect runs the workflow inside Epic, athenahealth and eClinicalWorks. The program is “paid for by health plans,” and it serves plans across Medicare Advantage, Medicaid and ACA lines through their primary care networks.

Cotiviti (including Edifecs)

Cotiviti completed its acquisition of Edifecs in March 2025, and edifecs.com now redirects to Cotiviti. Its portfolio “includes prospective, concurrent, and retrospective risk adjustment capabilities”: suspect analytics, chart retrieval and coding services with NLP, pre-visit prep with “physician final say,” post-visit review available as SaaS or a service, concurrent risk adjustment inside the claims pipeline, and encounter submission. It serves health plans and, through a provider suite, health systems and ACOs.

Arcadia

Arcadia, founded in 2002, places risk adjustment in Ascent Performance, which it says “unifies quality measurement and risk adjustment.” It describes its approach as “prospective-first,” with “integrated clinical workflows” for prospective and concurrent risk adjustment, point-of-care guidance inside the EHR, and AI add-ons for retrospective workflows. It serves providers, payers and ACOs.

Navina

Navina calls itself “the clinician-first AI copilot for value-based success.” It reconciles data from multiple sources for the point of care and offers “AI-powered HCC recommendations at the point of care,” along with care gap and quality tools, for physician groups, ACOs and health plans. See our Navina alternatives guide for a closer comparison.

Innovaccer and Lightbeam

Both offer risk adjustment as part of a wider value-based care platform. Innovaccer’s value-based care suite says it uses “AI at the point of care to identify gaps, improve coding accuracy, and discover potential missed conditions.” Lightbeam’s Provider Compass is an embedded, AI-powered tool that gives HCC coding guidance inside the provider’s EMR. Either fits best when you already run that platform for population health.

Zynix AI

Zynix AI works on the step most coding tools leave open: getting the patient in front of a clinician. For HCC gap closure, it ranks open HCC gaps, prepares clinicians with evidence before scheduled visits, and uses voice and text agents to invite patients with no visit booked. For Medicare Advantage plans and their networks, it invites members with undocumented chronic conditions to a visit with their primary care practice.

Zynix does not code charts or suggest diagnoses for submission. Clinicians evaluate the patient and document what they find, and your coders and existing risk adjustment tools take it from there. Zynix connects to 30+ EHR systems across 300+ connected instances, so one program can run across practices on different EHRs.

How to choose risk adjustment software

• You are a health plan with a large chart-review program: compare retrospective platforms and services such as RAAPID, Reveleer, Cotiviti and Optum, and ask how each removes unsupported codes as well as adding missed ones.
• You want clinicians to document accurately during the visit: compare point-of-care tools such as ForeSee Medical, Navina and Vatica, and check how prompts appear in your EHR.
• You already run a population health platform: check the risk module of Arcadia, Innovaccer or Lightbeam before adding a separate tool.
• Your gaps stay open because patients are not seen: add outreach and scheduling, which is where Zynix AI fits, alongside whichever coding tool you use.

In every case, ask how the tool supports the 2024 CMS-HCC model, how each suggestion links to chart evidence, and how it prepares you for RADV. For an evaluation checklist, see HCC gap closure software for ACOs.

Frequently asked questions

What is the best HCC risk adjustment software?

There is no single best tool; the right choice depends on where your program loses accuracy. Health plans with large chart-review programs usually compare retrospective platforms such as RAAPID, Reveleer, Cotiviti and Optum. Groups that want better documentation during the visit look at point-of-care tools such as ForeSee Medical, Navina and Vatica. Organizations whose gaps stay open because patients are not seen add outreach, such as Zynix AI.

What is the difference between prospective and retrospective risk adjustment?

Prospective risk adjustment happens before or during the visit: the clinician sees likely conditions and evaluates the patient, so documentation is complete when the visit ends. Retrospective risk adjustment reviews charts after the visit to find diagnoses that were documented but not coded, and to remove codes the record does not support. Concurrent review sits in between, checking the encounter or claim before it is billed.

Does HCC coding software need to support V28?

Yes. CMS completed the three-year phase-in of the 2024 CMS-HCC model, commonly called V28, and calculates 100% of Medicare Advantage risk scores with it from payment year 2026. Ask each vendor how its suspecting, coding logic and reporting map diagnoses to the 2024 model.

Can AI code HCCs on its own?

AI and NLP can find evidence and suggest codes, but a diagnosis has to come from a clinician who evaluated the patient and documented it. Several vendors in this guide say a coder or physician confirms each code. Ask each vendor where human review happens and how every suggestion links to evidence in the chart.

Is risk adjustment software only for Medicare Advantage plans?

No. Shared Savings Program ACOs also depend on CMS-HCC risk scores, which adjust their benchmarks, and several vendors also support ACA (HHS-HCC) and Medicaid risk models. Provider groups in risk contracts use the same tools to document accurately at the point of care.

Related reading

• HCC V28 Changes Explained: V24 vs V28 and What Applies in 2026 and 2027
• HCC Gap Closure Software for ACOs: What It Should Do and How to Evaluate It
• Navina Alternatives for ACOs and Value-Based Care Groups in 2026

Source notes

Centers for Medicare & Medicaid Services: CY 2024 Medicare Advantage Rate Announcement. https://www.cms.gov/files/document/2024-announcement-pdf.pdf

Centers for Medicare & Medicaid Services: 2026 Medicare Advantage and Part D Rate Announcement (fact sheet). https://www.cms.gov/newsroom/fact-sheets/2026-medicare-advantage-part-d-rate-announcement

ForeSee Medical: Risk adjustment software for providers and coders. https://www.foreseemed.com/risk-adjustment-software-providers-coders

ForeSee Medical: Medicare risk adjustment. https://www.foreseemed.com/medicare-risk-adjustment

Optum: Risk adjustment. https://business.optum.com/en/operations-technology/risk-adjustment.html

Optum: Optum Risk Analytics. https://business.optum.com/en/operations-technology/risk-adjustment/risk-analytics.html

Optum: Retrospective risk adjustment. https://business.optum.com/en/operations-technology/risk-adjustment/retrospective.html

RAAPID: Retrospective risk adjustment. https://www.raapidinc.com/retrospective-risk-adjustment/

RAAPID: Prospective risk adjustment. https://www.raapidinc.com/prospective-risk-adjustment/

Reveleer: Prospective risk adjustment (clinical intelligence). https://www.reveleer.com/solutions/clinical-intelligence

Reveleer: Retrospective risk adjustment. https://www.reveleer.com/solutions/risk-adjustment

Reveleer: EVE Hybrid AI announcement. https://www.reveleer.com/news/eve-hybrid-ai-risk-adjustment

Vatica Health: Risk adjustment for health plans. https://vaticahealth.com/risk-adjustment-for-health-plans/

Vatica Health: Home page. https://vaticahealth.com/

Cozeva + Vatica: Merger page. https://info.vaticahealth.com/vatica-cozeva

Cotiviti: Risk adjustment. https://www.cotiviti.com/solutions/risk-adjustment

Cotiviti: Cotiviti Completes Acquisition of Edifecs. https://www.cotiviti.com/press-release/cotiviti-completes-acquisition-of-edifecs

Arcadia: Ascent Performance, arcadia.io/ascent/performance/, and About, arcadia.io/about/ (page text retrieved November 6, 2026; the site blocks automated link checks).

Navina: Home page. https://www.navina.ai/

Innovaccer: Value-based care. https://innovaccer.com/value-based-care

Lightbeam Health Solutions: TCM, CCM & Rising Risk Management (Provider Compass). https://lightbeamhealth.com/tcm-ccm-rising-risk-management/

About the author

Gautamdev Chowdary is co-founder and CTO of Zynix AI, where he leads engineering for the Zynix platform, its AI agents and ZynixLLM.