Welcome back to Care Decoded, the podcast where we make sense of the evolving world of healthcare documentation, coding, and clinical AI. In today’s episode, hosts Dr. Sunil Nihalani and Biodun Kajopaiye, Risk Adjustment and Stars Manager at CareFirst BlueCross BlueShield, dive into the seismic changes brought about by version 28 of the CMS HCC risk adjustment model. Whether you’re a seasoned pro or new to the world of risk adjustment, this episode will break down exactly what V28 is, how it’s shaking up provider and health plan workflows, and why specificity in documentation is more crucial than ever. From the altered landscape of risk score coefficients for common conditions like diabetes and obesity, to the growing role of pharmacy data and the challenges these shifts bring to providers, Dr. Nihalani and Biodun Kajopaiye share real-world insights, actionable advice, and strategies to help you lead with confidence through this moment of major change. If you want to understand how policy updates connect with patient care on the ground, you’re in the right place: let’s get decoding!

Timestamps:

00:00 Healthcare Advocate and Risk Adjustment Expert

06:29 "Improving Diagnosis Documentation and Risk Management"

10:25 RADV Impact on Health Providers

12:04 Risk Adjustment Incentives Explained

15:20 Health Care's Shift to Value-Based Contracts

18:28 Reducing Stress in Healthcare Providers

24:03 Towards Focused Healthcare Management

25:51 Optimizing Risk Adjustment Strategies

29:40 "Prioritize Clinical Perspective First"

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/

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