Medicare Advantage risk adjustment is no longer a growth lever. It is a compliance and cost-control function. CMS has expanded RADV audits to all eligible MA contracts, increased record reviews from 35 to up to 200 per plan, and grown its coding workforce from 40 to approximately 2,000 auditors. Federal estimates put unsupported MA diagnosis submissions at roughly $17 billion in annual overpayments. MedPAC pegs the 2026 figure even higher, at $76 billion.
In this climate, most risk adjustment software on the market was built for a world that no longer exists. Here is why that matters, and what health plans should demand instead.
The Problem With Legacy Risk Adjustment Solutions
Most risk adjustment vendors built their platforms during the revenue-first era. The design logic was straightforward: ingest charts, surface as many HCCs as possible, and maximize RAF scores. Speed and volume were the selling points. Compliance was an afterthought.
That design philosophy now creates three serious problems.
One-way coding is a regulatory red flag. Retrospective programs that exclusively add diagnoses without ever removing unsupported codes represent the single largest enforcement signal in current CMS guidance. DOJ investigations into major insurers have shown that systems designed primarily to increase risk scores can be treated as evidence of intent to inflate federal payments. If your risk adjustment solution only adds codes, it looks like a revenue engine to regulators.
Unexplainable AI creates audit exposure. CMS has confirmed it will use AI-powered tools to assist human coders during RADV reviews. Health plans using risk adjustment software that cannot explain its own recommendations are at a disadvantage. When CMS asks why a diagnosis was submitted, “the algorithm flagged it” is not a defensible answer.
Fragmented vendor stacks increase risk. Many health plans manage risk adjustment across three, four, or more vendors, each handling a different piece of the workflow. This creates data silos, inconsistent coding logic, and gaps in evidence trails. It also makes audit response chaotic and slow during the compressed timelines CMS now enforces.
What Compliance-Ready Risk Adjustment Software Looks Like
The risk adjustment vendors that will survive this transition share a few common traits.
They operate two-way retrospective models that both validate supported diagnoses and remove codes lacking clinical evidence. They use explainable AI that links every HCC suggestion to MEAT-based documentation (Monitor, Evaluate, Assess, Treat) so auditors can follow the reasoning. They consolidate workflows into a single platform rather than forcing health plans to stitch together point solutions. And they treat audit readiness as a default output of every coding decision, not a separate project triggered by an audit notice.
Where RAAPID Stands Apart
RAAPID’s Novel Clinical AI Platform was purpose-built for this compliance-first reality. Its proprietary Neuro-Symbolic AI combines neural network pattern recognition with structured clinical reasoning, producing transparent, audit-defensible evidence trails for every suggested HCC.
Unlike legacy risk adjustment vendors, RAAPID operates a true two-way model. The platform adds supported diagnoses and removes unsupported codes, addressing the exact pattern CMS has identified as high-risk. This approach has delivered over 98% coding accuracy and 60 to 80% productivity improvements for coding teams. One Fortune 500 payvider exceeded its accuracy benchmark by 21 percentage points during a proof-of-concept evaluation.
RAAPID is HITRUST certified, SOC 2 Type II compliant, and Azure-native. Health plans can deploy the platform within their own Azure tenant, keeping PHI entirely within their controlled environment. This addresses the data sovereignty, vendor consolidation, and governance concerns that CIOs and compliance officers raise in every evaluation.
The Bottom Line
Risk adjustment has shifted from a revenue function to a clinical and compliance discipline. The risk adjustment software you selected three years ago may now be your biggest source of regulatory exposure. Plans that want defensible coding, audit readiness, and a platform that regulators can trust are choosing RAAPID.
