New Year, New Opportunities for Comprehensive Patient Care

Each new year is a clean slate for capturing and reporting risk-adjustable conditions, which gives healthcare teams a powerful opportunity to redefine how they deliver care for patients. This is the time to look at risk adjustment as more than just a program of code capture and instead embrace the full spectrum of patient-centered care. Unfortunately, the key component of risk adjustment models is often lost.

Too many providers focus only on capturing ICD-10-CM codes. That narrow focus overlooks the reason these programs exist—and, in the process, sidelines the people these programs are meant to serve. The problem came into sharp focus at a recent industry conference: respected leaders talked about risk adjustment solely in terms of codes, never once mentioning patient engagement, chronic disease management, or the importance of documenting a plan of care.

This mindset has real consequences. Recent audits published by HHS OIG found up to 100% failure rates in some Medicare Advantage programs, where clinical records did not back up reported diagnoses for high-risk conditions. The lesson is clear: risk adjustment is not just a numbers game. A “risk score” is more than just a figure—it’s a reflection of the resources needed for each enrollee that must be based on thorough clinical evaluation and comprehensive documentation of an assessment, status, and plan of care.

The early days of 2026 are a perfect opportunity to focus on:

• Comprehensive, patient-focused assessments
• Clear, complete and accurate documentation of condition status and care plans
• Funding care according to real, documented health needs

The path forward isn’t just about compliance or financial alignment. It’s about restoring the focus of care delivery to its rightful place: on the patient, grounded in clinical evidence, and driven by a plan that supports real health outcomes.

Risk adjustment programs including Medicare Advantage, CMS MSSP, commercial ACA plans, and state Medicaid are designed to ensure patients receive care tailored to their specific needs, not just to tick boxes on a form or re-code conditions from a problem list. Fundamentally, all risk adjustment models are about fully assessing a patient’s health and matching resources to individual disease burdens to ensure every patient can access the care they deserve and that appropriate funding is allocated based on predicted needs.

The new year is the perfect time to schedule patients for thorough annual wellness or comprehensive care visits. This ensures clinical documentation that outlines the patient’s care needs and allows for early, accurate risk adjustment reporting. Practically speaking, most health plans won’t have 2026 membership rosters until March or even April, but provider organizations can use their 2025 end-of-year roster to identify those patients with high-risk conditions.

Right now is also a good time to review the 2025 roster to identify patients who weren’t seen in prior years and support proactive outreach and engagement in 2026. Verifying the member hasn’t made changes to their coverage or designated primary care provider is a must to ensure patient-provider attribution is still in effect.

Technology can be an enormously powerful driver of risk adjustment success, whether in the form of analytics, a suspecting or pre-visit review tool, or even a partner to assist with patient engagement activities. Today’s challenging health care environment requires increased efficiency, an ability to scale and measurable improvements—all of which can be supported through partnership with an experienced technology vendor.

Make this the year your practice elevates every patient encounter. Quality patient care, whether in a risk adjustment model or not, should be about caring for the whole person, every time. By putting the focus back on the patient, providers can achieve more complete and accurate clinical documentation that translates to clinically-specific coding and, in the end, supports more effective risk adjustment.