MA at the crossroads: Balancing quality and compliance at scale

Medicare Advantage (MA) is reaching an inflection point. For many years, MA plans prioritized growth, and the result is that more than half of all eligible seniors are enrolled in MA. This year at Becker’s Payer Roundtable, it became clear that sustainability has become more urgent than growth. Plans, providers, and policymakers are all navigating an environment that's more complex and more heavily scrutinized than in years past.

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Reveleer participated in a Becker's session titled “Medicare Advantage Growth Challenges: Quality and Compliance”. The session surfaced three themes running across the conference: including the strain between providers and health plans, the growing demands of Star Ratings, and the intensifying pressure on risk adjustment. The main question that arose was not whether value-based care was still viable, but how the industry can better align to meet multiple goals even as costs rise and regulatory pressure increases.

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Provider-payer strain is increasing

Health systems across the country are pulling back from MA contracts, citing reasons including inadequate reimbursement, prior authorization friction, and the administrative burden of managing multiple payer relationships. Nevertheless, panelists and attendees at Becker’s seemed to agree that this strain did not represent a failure of MA or value-based care more generally. Instead, it is due in large part to misaligned incentives and insufficient data infrastructure.

Many provider organizations are still operating with fee-for-service mindsets and systems largely due to varying payment structures. Health plans have not invested sufficiently in the relationships and transparency that make value-based contracts with providers work well. Unfortunately, shrinking margins and rising costs are introducing distrust between plans and providers.

As a result, provider organizations are becoming more selective in the contracts they engage in. In some markets, health systems are limiting contracts to no more than three MA plans. They are choosing based on relationship quality, not just contract terms. Plans that want to stay on the short list will need to invest in interoperability, education, and the infrastructure that give providers visibility into risk, claims lag, and shared performance. Technology and data matter, as do the human relationships that make that infrastructure meaningful.

Quality performance must be an enterprise-wide commitment

During “Medicare Advantage Growth Challenges: Quality and Compliance”, Essence Healthcare’s sustained 4.5-star performance was offered as a model. Panelist Saria Saccocio, MD, Essence's Chief Medical Officer, attributed this to their prioritization of strong primary care-patient relationships, early annual wellness visits, and continuity of care. Stars performance, Dr. Saccocio noted, is a byproduct of doing the fundamentals of primary care well at scale.

Humana’s experience offered a more cautionary counterpoint. After losing ground when CMS raised performance thresholds, Stars performance has become the company’s top priority. It requires enterprise-wide focus and deep, sustained provider engagement.

The regulatory environment is also shifting the playing field when it comes to quality performance. CMS is eliminating 11 existing measures and moving toward clinical outcomes-oriented metrics. Member experience, measured through CAHPS and Medicare Health Outcomes Survey (HOS), will account for nearly half of Stars Ratings going forward. Mock CAHPS surveys, real-time analytics, and targeted outreach are becoming table stakes. Panelists at Becker’s noted that plans treating Stars as a downstream reporting exercise rather than embedding it into operations will find themselves chasing a moving target.

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Risk adjustment is no longer a growth lever, it’s a compliance imperative

Perhaps the theme that carried the most urgency this year at Becker's was the importance of risk adjustment accuracy. Michael Bagel, Vice President of Policy at the Alliance of Community Health Plans, said “We’re going to see more audits and more settlements than we have before, because now it’s not just civil, it’s criminal. DOJ is coming after folks for risk adjustment.”

Recent DOJ settlements and CMS enrollment actions against major MA plans have made it more critical than ever that risk adjustment accuracy be an organizational priority. They also signal to the broader industry that regulatory scrutiny is no longer a distant risk.

Risk adjustment was designed to ensure that plans serving sicker, higher-need populations are adequately funded to do so. However, over time, competitive pressures have turned risk score optimization into an end in itself, attracting scrutiny for the gap between documented diagnoses and actual care management.

Discussion at Becker's aligned around the fact that there needs to be a genuine shift in risk adjustment: from retrospective chart reviews to prospective, point-of-care documentation and gap closure. This shift can help risk adjustment continue to serve its purpose, ensuring resources go where they are needed, while also improving outcomes. Strong provider partnerships and real-time analytics should serve as the foundation of a defensible and functional risk adjustment program. Plans that embed auditing and validation into daily workflows, rather than treating them as periodic events, will be far better positioned in the new era of MA.

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The ones that I have seen perform a little bit better are those that are not relying as much on retrospective chart retrieval, and coding. They understand, they're trying to partner with their providers. They want to move that gap closure up on the prospective side at the point of care, supporting those providers with insights to drive better capture, clinical documentation improvement and doing that education.
_{- Dave DeHommel, VP Payer Strategies, Reveleer}

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What the next three years will demand of MA

At Becker’s, panelists were largely aligned that the current MA framework will look meaningfully different in the next few years. CMS is signaling a continued move toward concrete, outcomes-based quality metrics. Many of the measures plans have built programs around are likely to be replaced or restructured.

Financial pressure adds urgency to this uncertainty. CMS rate increases have been less than anticipated, and new therapies are contributing to rising healthcare costs all while member expectations are rising.

Questions arising right now include:

1. How will CMS define and operationalize outcomes-based metrics in practice?
2. How can organizations prioritize investments in risk adjustment and quality improvement?
3. What will the impact of member churn and benefit disruptions be for member experience and plan performance?
4. Will a durable model that supports both quality and compliance at scale emerge before the next major regulatory cycle?

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Providers, plans, and policymakers alike are still figuring out the answers to these questions. However, the organizations best positioned to respond are those investing now in technology, relationships, and workflows that support the disparate demands of value-based care simultaneously.

The path forward: Collaboration, data, and point-of-care execution

As the market shifts across regulatory, operational, and financial dimensions, health plans that will grow in this environment share a few characteristics.

1. They are tightening alignment with provider partners through joint operating reviews, transparent data-sharing, and shared incentives.
2. They are investing in interoperable data infrastructure to support both quality and risk adjustment at the point of care.
3. They are treating member experience as a strategic lever given its growing weight in Stars performance.

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Dr. Saccocio summed up the future of MA: “I really believe in Medicare Advantage because it is value-based care. As a primary care physician, this is at the core of what we do. So when I say don't stop believing, don't stop believing in the relationship.”
_{- Saria Saccocio, MD,Chief Medical Officer, Essence Healthcare}

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At Reveleer, our team helps health plans balance enrollment, risk, quality, and audit readiness in ways that support providers and members. The complexity of the current MA environment is substantial, but so is the opportunity for organizations that are willing to build for it with intention.

The new MA equation: One discipline, not three programs

The plans that come out ahead in this environment will treat provider alignment, quality performance, and risk adjustment compliance as a single operating discipline — not three separate programs run by three separate teams on three separate datasets. The Reveleer Platform unifies retrieval, risk adjustment, quality improvement, and member management on one data layer, giving health plans the infrastructure to run point-of-care documentation, defensible coding, and audit-ready CMS submissions from the same source of truth. Schedule a custom demo to see how Reveleer helps MA plans align quality, risk, and compliance.