The rules of risk adjustment have changed. Federal estimates suggest MA organizations may be submitting unsupported diagnosis data resulting in roughly $17 billion in annual overpayments. CMS is now auditing all eligible Medicare Advantage contracts every payment year, reviewing up to 200 enrollee records per contract. In this environment, the risk adjustment software you choose is no longer a productivity decision. It is a compliance decision. The wrong risk adjustment solution can create the very regulatory exposure it was supposed to prevent.
This guide outlines what health plan leaders should look for when evaluating risk adjustment vendors in 2026 and beyond.
Why Your Risk Adjustment Solution Now Carries Compliance Risk
For years, health plans evaluated risk adjustment software on speed, volume, and the number of HCCs it could surface. The goal was simple: find more codes, increase RAF scores, maximize reimbursement. That model is now a liability.
DOJ enforcement actions against major insurers have demonstrated that coding systems designed primarily to increase risk scores can be interpreted as evidence of intent to inflate federal payments. CMS completed audits for Payment Years 2011 through 2013 and found overpayment rates between five and eight percent, with recoveries now beginning. MedPAC estimates MA overpayments could reach $76 billion in 2026 alone.
This means risk adjustment vendors are no longer just technology partners. They are compliance partners. And the wrong partner creates organizational legal exposure.
What to Look For in Risk Adjustment Software
When evaluating risk adjustment software today, speed and HCC volume still matter, but they are no longer the primary criteria. Here is what should top every evaluation:
Two-way coding (adds and removes). The single largest enforcement red flag in current CMS guidance involves retrospective programs that only add diagnoses without ever removing unsupported codes. Any risk adjustment solution that operates as a one-way code addition system creates regulatory risk. The right platform both validates supported diagnoses and flags codes that lack clinical evidence for removal.
Explainable AI with evidence trails. CMS has confirmed it plans to deploy AI-powered tools to support human coders during RADV audits. Health plans need risk adjustment software where every suggested HCC includes transparent clinical reasoning and MEAT-based evidence (Monitor, Evaluate, Assess, Treat). If your AI cannot explain its recommendations in terms an auditor can follow, it becomes a compliance risk rather than a compliance asset.
Audit-ready documentation from day one. With CMS now initiating audits approximately every three months, health plans cannot afford to scramble for evidence when an audit notice arrives. The best risk adjustment vendors build audit readiness into every coding decision, creating defensible evidence trails as a natural byproduct of the workflow rather than an afterthought.
Enterprise-grade governance. CIOs and compliance officers are increasingly concerned about ungoverned automation and shadow AI tools. Risk adjustment software must be auditable, governable, and transparent, something your compliance team can monitor and your auditors can trust.
Why RAAPID Leads Among Risk Adjustment Vendors
RAAPID’s Novel Clinical AI Platform was built for this exact regulatory moment. While many risk adjustment vendors are retrofitting legacy tools to meet new compliance demands, RAAPID’s platform was purpose-built around defensible accuracy from the start.
RAAPID’s proprietary Neuro-Symbolic AI combines the pattern recognition of neural networks with structured clinical reasoning logic. This means every HCC suggestion comes with a transparent evidence trail showing the clinical documentation that supports it. Coders see the reasoning. Auditors can follow it. Compliance teams can govern it.
The platform operates as a two-way risk adjustment solution, both adding supported diagnoses and removing codes that lack adequate clinical evidence. This compliance-first approach has delivered over 98% coding accuracy, 60 to 80% productivity improvements for coding teams, and chart review times reduced from 40+ minutes to under 8 minutes per chart. One Fortune 500 payvider achieved 86% out-of-the-box accuracy during proof-of-concept evaluation, exceeding their benchmark by 21 percentage points.
RAAPID is HITRUST certified, SOC 2 Type II compliant, and deploys natively on Microsoft Azure, with the option to run within a health plan’s own Azure tenant so PHI never leaves their controlled environment.
The Question Every Health Plan Should Ask Its Risk Adjustment Vendors
Before signing or renewing any risk adjustment software contract in 2026, every health plan leader should ask one question: “If CMS audited the coding decisions your platform helped produce, would the evidence trail demonstrate clinical accuracy, or revenue intent?”
Risk adjustment has shifted from a revenue function to a clinical, compliance, and enterprise AI discipline. Defensible coding is the foundation of that future. The risk adjustment vendors who understand this are the ones worth keeping.
