V28 RAF measured
1.21
The HCC Operator · Issue #1 · May 2026
V28 condition map shifts and the recapture window.
V28 dropped 200 plus ICD-10 codes from the HCC map, re-weighted 2,300 conditions, and the average MA practice is staring down a 9.3 percent RAF drop without intervention. The recapture window is open until the calendar year closes. This issue walks the condition remap, the monthly capture velocity, the AWV lever, and a ten-item checklist for the next four weeks.
01Editor's note
This is Issue #1 of The HCC Operator. It is written for the people who carry the captured revenue number. Each issue covers three industry shifts, an operator checklist, a field spotlight, reader questions, and a free audit offer. No conference circuit talk, no buzzwords, no em dashes. If you read the whole issue, you should know what to ask for on Monday.
Lead 01 · The condition remap
The V28 cut: 200 codes out, 2,300 re-weighted.
V28 is fully phased in for the 2026 payment year. CMS removed more than 200 ICD-10 codes from the HCC mapping entirely and re-weighted approximately 2,300 conditions. The down-weighted buckets are unspecified vascular disease, depression categories that were re-tiered, and chronic kidney disease which moved into tighter stage specificity. The buckets that held or improved are diabetes with manifestations, congestive heart failure, COPD, and several cancer categories.
The practice impact varies by panel mix. A primary care panel weighted toward older diabetics with manifestations and CHF may see a smaller hit than a panel skewed toward depression and unspecified vascular disease. The average MA practice we audit is seeing a 9.3 percent RAF drop on the same population, which translates to roughly 40 to 90 dollars of lost PMPM depending on the contract. None of this is because patients got healthier between coding years. It is the model. Coders trained on V24 conventions are still coding to V24, and the gap shows up in the next reconciliation.
V24 vs V28 weight delta · top 6 categories
Lead 02 · The recapture window
The window is tighter than most teams realize.
The CMS attribution period for Medicare Advantage is the calendar year. A chronic condition has to be coded and documented at a face-to-face encounter inside that year for the RAF to count. The operator window has three phases. January through September is the code-and-document phase on routine visits. October through November is the AWV catch-up phase. December is the close window for anything still open.
A suspect identified in November lands too late for the current year unless a visit is already on the schedule. Most groups we audit run their suspect engine quarterly. The math says it should run weekly from June onward and daily from October onward. The cost of a missed conversion in November is the same as a missed conversion in February, but the recovery probability collapses below 20 percent once the calendar turns. Run the engine on a faster cadence and the conversion rate moves with it.
Monthly capture velocity · % of suspects converted
Lead 03 · The AWV lever
AWV completion is the highest-leverage operational lift.
Top-quartile MA-heavy groups run 88 percent AWV completion. Bottom-quartile sits at 41 percent. The correlation between AWV completion and RAF lift is roughly 0.10 RAF per 25-point AWV gain in our audit data. A practice moving from 50 to 75 percent AWV completion picks up 0.10 RAF on average, which is meaningful at any contract rate. The AWV is the only annual visit that pays the practice to do a complete chronic condition review under MEAT.
AWV completion % vs RAF lift · 84-practice scatter
02Data deep dive: V24 to V28 condition impact
Vascular disease and depression carry the largest dollar hit because the V24 weights leaned heavily on them and the codes were both common and easy to capture. CKD moved into stage specificity so the practice has to code the stage, not the unspecified bucket. The categories that held or improved are the ones with clear documentation requirements. Diabetes with manifestations is up because the model rewards the specificity. The net story is that a practice that rebuilt its V28 fee schedule, ran AWV catch-up, and ran a weekly suspect engine recovered the 9.3 percent drop and added 6.1 percent on top.
03Operator's checklist: ten things this month
Ten actions a CFO or RCM director should have on the calendar for the next four weeks. Each one is a discrete task with an owner and a date, not a principle.
01
AWV schedule audit
Pull AWV completion by panel and rank the bottom decile of patients by gap days. Schedule the top 50 this week.
02
V28 fee schedule rebuild
Replace the V24 weights in every PMPM model with the V28 weights for the conditions on your top 20 chronic list.
03
Suspect queue daily review
Move the suspect engine from quarterly to weekly. From October forward, run it daily and route to the AWV scheduler.
04
Chronic condition re-coding audit
Sample 50 charts on the re-tiered categories, CKD, vascular, depression. Confirm V28 specificity and MEAT evidence.
05
Gap closure dashboard
Stand up a single weekly view of open gaps by patient with owner, last visit date, and the specific condition to address.
06
Panel mix RAF review
Run a V28 modeled RAF by primary care panel. Identify the panels with the largest variance and brief the lead provider.
07
CDI clinician feedback loop
Weekly 15-minute huddle with the CDI lead and a rotating provider. Walk the three highest-impact missed codes from the week.
08
Compliance audit
Pull 25 charts that closed last month with HCC codes. Confirm each code is supported by a MEAT element in the current note.
09
Payer reconciliation
Reconcile last month's MA PMPM payments against the modeled V28 RAF. Track variance by plan and open inquiries on outliers.
10
Vendor scorecard
Score every risk-adjustment vendor on V28 retraining, AWV scheduling capability, and audit defense. Sunset what fails.
04Field spotlight
Anonymized engagement · 7-month outcome
9-clinic MA group: V24 RAF 1.14 to V28 RAF 1.21.
A 9-clinic Medicare Advantage primary care group with roughly 3,800 attributed lives. Pre-engagement V24 RAF was 1.14. The V28 modeled drop was to 1.04. The group engaged ASP-RCM on V28 fee schedule rebuild, AWV scheduling, and a real-time suspect engine wired to the EHR. Seven months later, the measured V28 RAF was 1.21, AWV completion was 81 percent, and the incremental PMPY revenue was 3.6 million dollars.
AWV completion
81%
Incremental PMPY
$3.6M
05Reader Q and A
Is V28 phase-in over yet?
Yes. Payment year 2026 is the first year of 100 percent V28 weights. The blended period is over. Every PMPM you receive this year is calculated on V28, which is why the gap is showing up now even though the rule was finalized in 2023.
Does AWV completion need an annual cadence?
Yes. Every chronic condition has to be re-affirmed at a face-to-face encounter inside the calendar year. The AWV is the cleanest single visit that supports a full panel review. Skip a year on a given patient and you lose the HCCs on that patient for the year.
Which categories should we re-validate first?
Start with the re-tiered buckets, not the dropped ones. CKD stages, vascular disease, and depression. After those, walk the top 20 chronic conditions on your panel and confirm each has a current-year encounter with MEAT evidence.
06Free HCC capture audit
Send 90 days of MA claims, your AWV completion report, and your attributed life roster. Inside 30 days we return a 4-page written audit covering current capture rate, peer benchmark, top ten missed HCCs, projected V28 RAF after recapture, and an annual recoverable revenue range. Request the audit. No demo required.
07FAQ
What changed in V28?
CMS removed more than 200 ICD-10 codes from the HCC mapping and re-weighted approximately 2,300 conditions. The model is now fully phased in for the 2026 payment year. The practical consequence is that the same patient panel produces a lower RAF score under V28 than it did under V24, and the average MA practice is seeing a 9.3 percent RAF drop unless coding and documentation were retrained to the new logic.
What is the recapture window?
The CMS attribution period for Medicare Advantage is the calendar year. A chronic condition has to be coded and documented at a face-to-face encounter during that year to count toward the RAF score. The practical operator window is January through September for code-and-document on routine visits, and October through December for AWV catch-up. Suspects identified in November rarely make the year unless a visit is already scheduled.
Why is AWV completion the highest-leverage lever?
The AWV is the only annual visit that pays the practice to do a complete chronic condition review and assessment. Top-quartile MA-heavy groups run 88 percent AWV completion. Bottom-quartile sits at 41 percent. Across our audit data the correlation between AWV completion and RAF lift is roughly 0.10 RAF per 25-point AWV gain. Closing the AWV gap is the cheapest dollar of incremental RAF revenue a practice can buy.
Which V28 categories moved the most?
The biggest down-weight buckets are unspecified vascular disease, depression categories that were re-tiered, and the chronic kidney disease bucket which was re-tiered. The categories that held or improved are diabetes with manifestations, congestive heart failure, COPD, and several cancer categories. The net practice impact depends entirely on panel mix.
Which conditions should we re-validate first?
Start with the conditions that were re-tiered rather than dropped. CKD stages, vascular disease, and depression categories each need re-coded to the V28 specificity level. After that, walk the top 20 chronic conditions on your panel and check that each one has a current-year encounter with MEAT evidence. Conditions that did not survive the V24 to V28 map drop off the queue entirely.
Does AWV need an annual cadence to count?
Yes. Every chronic condition must be re-affirmed at a face-to-face encounter during the calendar year. The AWV is the cleanest single visit that supports a full panel review under MEAT. Practices that skip a year on a given patient lose every HCC on that patient for the year, regardless of how well documented the prior year was.
What does the free HCC capture audit return?
Send 90 days of MA claims, your AWV completion report, and your attributed life roster. Inside 30 days we return a 4-page written audit covering current capture rate, peer benchmark, top ten missed HCC codes by frequency, projected V28 RAF after recapture, and an annual recoverable revenue range. The audit is yours to keep with no demo requirement.
How does the spotlight group recover RAF after a V28 drop?
The 9-clinic MA group we describe in the spotlight engaged on V28 fee schedule rebuild, AWV scheduling, and a suspect engine. They closed AWV completion to 81 percent in seven months, recaptured the V24 to V28 delta, and finished at a measured V28 RAF of 1.21 against a modeled drop to 1.04. The lift was 3.6 million dollars in incremental PMPY revenue.