The New Era of HCC Risk Adjustment: What CMS Changes Mean for Providers
- Deeya Chopra
- 2 days ago
- 2 min read
Hierarchical Condition Category (HCC) risk adjustment used to be something many leaders left to coders and actuaries. That is no longer the case. With the latest CMS risk adjustment model updates and tightening oversight, HCC accuracy now sits at the center of value based care performance, especially for ACOs and Medicare Advantage organizations.
The shift to the 2024 CMS HCC model (V28) for Medicare Advantage and the related changes in how CMS applies risk adjustment to Shared Savings Program benchmarks have raised the stakes for every organization that depends on risk-adjusted revenue.
Why HCC Risk Adjustment Matters In Value-Based Care
HCC risk adjustment exists to match payment to patient complexity. In practical terms, it affects:
Medicare Advantage capitation rates, on risk scores that reflect a member’s disease burden.
Shared Savings Program benchmarks, via prospective risk scores that set spending targets for ACOs.
ACO REACH and other innovation models, which also rely on HCC-based risk adjustment.
If risk scores are too low because conditions are under-documented or miscoded, organizations carry more risk than they are paid for. If scores are artificially inflated through aggressive coding, they face audit exposure and clawbacks.
What Changed With The CMS HCC Model
Over the last two years, CMS has moved to a revised HCC model known as V28 for Medicare Advantage and is aligning Shared Savings Program methodologies with this new model.
Use of the same HCC model across benchmark and performance years.
Phase in of V28, blending older and newer models.
Updated HCC groupings and coefficients.
How These Changes Affect ACOs And Provider Groups
For ACOs, VBC groups, and large provider organizations, the new HCC environment shows up in three visible ways:
Benchmarks and shared savings become more sensitive to documentation quality.
Coding intensity has less room to hide.
High-need and high-risk populations require more precise management.
Common Pitfalls Under The New HCC Model
How AI-Driven Tools Like ZynGap Help
ZynGap is Zynix’s real-time HCC and quality intelligence engine. It surfaces risk adjustment insights that matter most.
Scan clinical notes and problem lists for uncaptured conditions.
Highlight diagnoses that no longer map to payment HCCs.
Generate provider-friendly worklists.
Track RAF and HCC metrics over time.
Building A Year-Round HCC Strategy
Prospective identification.
Point of care prompts.
Post-visit review.
Continuous monitoring.
What Leaders Should Do Now
Align clinical, coding, and analytics teams around one source of truth.
Invest in tools that surface opportunities in real time.
Review documentation, training, and feedback loops.
Make responsible AI part of the operating model.
Conclusion
The new era of HCC risk adjustment changes what it takes to succeed in value-based care. Organizations that build accurate, clinically grounded, and well-governed risk adjustment processes will be better positioned to thrive.
