Medicare Advantage primary care · 12,000 lives · CMS-HCC V28

Average RAF lifted from 0.90 to 1.00. Every point documented.

A group was leaving RAF on the table as the CMS-HCC V28 model reached 100 percent phase-in. ASP-RCM stood up suspect identification, annual recapture, and MEAT documentation discipline. RAF and PMPM recovered. Capture stayed compliant, documented, not inflated.

Get a RAF gap audit → See the recapture funnel

Setting

MA Primary Care

Panel

12,000

Model

CMS-HCC V28

Payment year

2026

Engagement

12 months

Avg RAF

0.90→1.00

Result snapshotThe four numbers that moved.

Average RAF

0.90 → 1.00

PANEL-WIDE AVERAGE

Chronic recapture

71% → 96%

PRIOR-YEAR HCCs RE-CONFIRMED

PMPM uplift

+11%

RAF-LINKED, DOCUMENTED

MEAT compliance

100%

CAPTURED CODES AUDIT-READY

The signature viewRAF gauge and the January 1 reset.

RAF before → after

PANEL AVERAGE RAF · V28 · +0.10 POINTS

Chronic HCCs reset every Jan 1

The situationRAF left on the table. Three leaks. One score.

BASELINE Average RAF 0.90 as V28 hit full phase-in. Only 71 percent of prior-year chronic HCCs recaptured. The illness burden was real; the score understated it.

Leak 01 · Recapture

Chronic HCCs never re-confirmed.

RECAPTURE

71%

HCCs LOST

29%

Leak 02 · V28 shift

Coded to the old V24 map.

V28 PHASE-IN

100%

RAF EROSION

-0.06

Leak 03 · MEAT

Problem-list codes with no MEAT.

UNSUPPORTED

14%

AUDIT RISK

HIGH

The fix · suspect funnelSuspect to confirmed. Every prompt at the point of care.

RULE A suspect is a prompt to evaluate, never a code. The provider confirms or rules it out with MEAT. Capture is documented, not assumed.

The method · four moves

How ASP-RCM ran compliant recapture.

Suspect identification. Prior-year HCCs not yet recaptured, medication-implied diagnoses, abnormal labs, and specialist notes surfaced into a per-provider worklist.
Point-of-care prompts. Open suspects pushed to the provider inside the encounter, tied to the Annual Wellness Visit as the once-a-year recapture touchpoint.
MEAT documentation. Every confirmed condition documented as Monitored, Evaluated, Assessed, or Treated. No MEAT, no code. Problem-list carryover blocked.
V28 mapping refresh. Conditions re-mapped to the CMS-HCC V28 payment categories so recapture targeted codes that still contribute to RAF at full phase-in.

Recapture worklist V28 · point of care

Diabetes w/ complicationsPRIOR-YEAR HCC

CONFIRM

96%

CHF, chronicPRIOR-YEAR HCC

CONFIRM

94%

CKD stage 4MED-IMPLIED SUSPECT

EVALUATE

68%

Major depressive disorderLAB / SCREEN SUSPECT

EVALUATE

61%

Vascular diseaseNO MEAT · BLOCKED

HOLD

ASP-RCM · HCC Recapture Program Compliant · Documented · Not inflated

The recapture ledgerTop HCC categories, baseline to recaptured.

Illustrative of a 12,000-life panel under CMS-HCC V28. Recapture rate is the share of members with the condition present in the record who were re-confirmed to the MEAT standard on a current-year encounter. No code was placed without MEAT support.

Condition category	V28 HCC	Recapture baseline	Recapture after	Documentation
Diabetes with chronic complications	HCC 37	70%	97%	MEAT verified
Congestive heart failure	HCC 226	73%	96%	MEAT verified
Chronic kidney disease, stage 4	HCC 327	66%	94%	MEAT verified
Chronic obstructive pulmonary disease	HCC 280	72%	95%	MEAT verified
Major depressive disorder, recurrent	HCC 155	64%	92%	MEAT verified
Vascular disease	HCC 264	69%	93%	MEAT verified

The outcomeTwelve months. RAF and PMPM recovered.

Baseline · before

Average panel RAF0.90

Chronic HCC recapture71%

Annual Wellness Visit rate54%

Codes without MEAT14%

RAF understated true illness burden

Steady state · after

Average panel RAF1.00

Chronic HCC recapture96%

Annual Wellness Visit rate82%

Codes without MEAT0%

+0.10 RAF · +11% PMPM · fully documented

The score was low because the work was invisible, not because the patients were healthy. We did not add a single diagnosis the record did not already support. We closed the gap between what was documented and what was coded, and we made every capture defensible on audit.

ASP-RCM · Senior Partner Team · HCC Practice

The guardrailsRecapture is not inflation.

Every capture in this program passes a compliance gate before it reaches a claim. The distinction between recapture and inflation is the whole point. One closes a documentation gap for a condition the patient has. The other invents burden the record cannot support. Only the first is billed.

Suspects are prompts, not codes. Chronic conditions reset every January 1 and must be re-documented in a current encounter. MEAT is required on every risk-adjusting diagnosis. V28 mapping keeps recapture pointed at codes that still carry RAF.

Gate 04 · Audit trail

Every captured HCC linked to the encounter note and MEAT evidence

▲

Gate 03 · MEAT required

Monitored, Evaluated, Assessed, or Treated in a current-year visit

▲

Gate 02 · Provider confirmation

Suspect confirmed or ruled out at the point of care, never auto-coded

▲

Gate 01 · Suspect signal

Prior-year HCC, med-implied diagnosis, abnormal lab, specialist note

Common questionsFrequently asked: V28 RAF recapture.

What is RAF and why does it drive PMPM?

RAF is the Risk Adjustment Factor, a numeric score CMS assigns each Medicare Advantage member from demographics plus captured HCC diagnoses. The plan is paid a per-member-per-month (PMPM) amount that scales with RAF. A member at RAF 1.0 draws the benchmark payment; a member at 0.90 draws roughly ten percent less even when the underlying illness burden is identical. When documented conditions are not captured, the RAF understates the true burden and PMPM is left on the table.

Why do chronic HCCs reset every January 1?

CMS risk adjustment is a calendar-year model. Every chronic condition that contributes to RAF must be re-documented and re-coded during the current dates of service each year. A diabetic with complications coded in 2025 contributes nothing to the 2026 RAF unless the condition is captured again in a 2026 encounter. This is the annual recapture requirement. Conditions do not carry forward. On January 1 the slate is blank.

What is V28 and how is it different?

V28 is the CMS-HCC risk adjustment model that reaches 100 percent phase-in for payment year 2026. It reduced the number of payment HCCs, restructured several condition categories, and removed or re-weighted codes that previously contributed to RAF. Groups that coded to the older V24 mapping saw RAF erode as V28 phased in. Recapture under V28 means confirming the conditions that still map to a payment HCC and documenting them to the current standard.

What is MEAT documentation?

MEAT stands for Monitored, Evaluated, Assessed, Treated. It is the documentation standard that supports a risk-adjusting diagnosis. A condition listed on a problem list without evidence that it was monitored, evaluated, assessed, or treated during the encounter does not support the code. MEAT is the compliance backbone of recapture. Capture must be documented, not asserted.

Is this upcoding?

No. Recapture confirms conditions the patient actually has and that are documented to the MEAT standard during a current encounter. It closes the gap between conditions present in the record and conditions coded on the claim. It does not add diagnoses the patient does not have. The distinction between recapture and inflation is the entire point: one is compliant, the other is fraud.

What is a suspect condition?

A suspect is a condition the record suggests the patient may have but which has not been confirmed and coded this year. Signals include a prior-year HCC not yet recaptured, a medication that implies a diagnosis, an abnormal lab, or a specialist note. A suspect is a prompt to evaluate at the next visit, not a code. The provider confirms or rules it out at the point of care.

How does the Annual Wellness Visit help?

The Annual Wellness Visit is a covered Medicare encounter built around a health risk assessment and a review of chronic conditions. It is the natural once-a-year touchpoint to recapture every chronic HCC and evaluate open suspects. Groups that drive AWV completion give every member at least one structured opportunity for recapture inside the calendar year.

Why anonymize the group?

Client agreements include reciprocal confidentiality. The frameworks are real and the archetype numbers are illustrative of a group of this size. A senior partner can walk you through methodology and arrange a reference conversation under NDA once both sides agree.

Find the RAF you are leaving on the table.

A RAF gap audit shows where documented conditions never reached a current-year claim, which chronic HCCs went unrecaptured, and where MEAT support is thin. You get a written read on recapture opportunity and a compliant capture plan under V28. Recapture is documented, not inflated.

Get a RAF gap audit Read the V28 playbook