The Future of Risk Adjustment: Preparing for CMS Audits, Extrapolation, and AI Technology

Welcome back to Care Decoded, the podcast where we make sense of the fast-evolving world of documentation, coding, and clinical AI to power better patient care. In today’s episode, host Michael Lesnik welcomes healthcare innovation and policy leader Dr. Shannon Decker for a deep dive into the major changes facing risk adjustment as we approach 2026. You’ll hear Michael Lesnik and Dr. Shannon Decker tackle the ripple effects of a recent court ruling that vacated CMS’s RADV final rule and what that means for audit compliance, health plans, and provider groups. As the landscape shifts, they’ll explore how AI is revolutionizing regulatory oversight, the urgent need for data accuracy, and why quality and total cost of care matter more than ever in the value-based care era. This episode is packed with practical insights for health plan leaders and providers alike, including firsthand stories, strategies to shore up documentation workflows, and tips for staying competitive as technology and compliance expectations accelerate. If you want to be ready for the future of risk-based contracting and avoid common blind spots, you won’t want to miss it. Timestamps: 00:00 "CMS Compliance Pause Insights" 06:26 AI in Medical Data Challenges 07:12 "Good Data is Essential" 10:16 "Risk Adjustment Impacts Provider Groups" 14:15 AI Advancements and Hiring Delay 17:27 Improving Claims & Patient Care 22:15 Optimize Documentation and Systems Effectively 24:49 Risk Improvement Strategies 31:18 Renegotiating Contracts and Data Strategy 32:16 Streamlining Medical Record Management 35:24 Unfair CAHPS Survey Impact 41:05 Advancing Physician Support Effectively 44:30 Investing for Growth and Healthcare Challenges 46:13 "Thoughtful System Implementation Strategy" 49:12 "Risk Adjustment: Accuracy Matters" Podcast's Website - https://caredecoded.com/ Dr. Sunil Nihalani - CEO and Founder at Inferscience - https://www.linkedin.com/in/sunil-nihalani-a6983a5/ Inferscience - https://www.inferscience.com/ Podcast Powered by TopHealth - https://tophealth.care/ “Disclaimer: Informational only. Not medical advice. Consult your doctor for guidance.”