CY 2027 paid plans $13B more. The DOJ probe expanded. OIG named the patterns.

Six federal actions in the last 90 days changed both the economics and the risk of MA risk adjustment. CMS handed plans an extra $13B in CY 2027 while killing unlinked chart-review sweeps. The DOJ acknowledged a criminal probe of UnitedHealth. OIG published its first major MA compliance program guidance since 1999. Star Ratings got overhauled with $18.6B shifting to plans. ACO REACH is sunsetting. And OIG documented $7.5B in MA payments tied to HRA-only diagnoses.

Each one moves your CY 2027 capture math. Together they tell you exactly what to fix this quarter. If this isn't useful, reply with "unsubscribe" and we'll take you off the list the same day.

01CMS paid plans $13B more in CY 2027. And killed retrospective sweeps.

On April 6, CMS finalized the CY 2027 Medicare Advantage Rate Notice at +2.48 percent net, roughly $13B in additional plan payments. A dramatic jump from the +0.09 percent / $700M figure CMS put in the January Advance Notice. The swing was driven by CMS abandoning its proposed transition to the 2024-calibrated risk adjustment model.

The structural change is in the methodology. CMS finalized the proposal to exclude unlinked chart-review diagnoses from risk score calculations. Projected federal savings: $7B in CY 2027 alone. For about a decade, retrospective chart sweeps have been a major HCC capture lever for MA-aligned medical groups. Starting CY 2027, sweeps without encounter linkage are dead money.

This week: pull your last 12 months of HCC capture. Sort by source. Encounter-linked versus chart-review-only. If chart-review-only is over 20 percent, you have a cliff.

02The DOJ probe puts the in-home HRA playbook on trial.

UnitedHealth's Q1 2026 SEC filing acknowledged a DOJ criminal investigation of its MA billing practices, opened in May 2025. Prosecutors are questioning physicians about UNH's coding and software-suggested diagnoses. On January 14, Senator Grassley released a 50,000-page majority staff report dissecting internal training materials and software prompts to clinicians tied to higher MA reimbursement.

The DOJ also has active False Claims Act litigation against Elevance, Independent Health, and Kaiser. Cigna paid $172,294,350 to settle FCA allegations in September 2025. The cited misconduct pattern: cursory in-home assessments with no follow-up testing, imaging, or treatment.

This week: pull every HCC captured in the last 12 months that has no downstream encounter activity. No lab, no imaging, no treatment plan, no follow-up note. That list is your audit exposure on a single screen.

03OIG's first major MA Compliance Program Guidance since 1999.

In February, HHS-OIG published the Industry-Specific Compliance Program Guidance for Medicare Advantage. First MA-specific guidance in 26 years. The document sets the enforcement framework that audits and DOJ FCA cases will reference for the next decade.

The ICPG calls out by name three operational practices: misusing chart reviews to mine for diagnoses, deploying in-home HRAs primarily to capture codes not considered in the care, treatment, or management of the enrollee, and downstream provider arrangements that pay for diagnosis capture. OIG released two contract audits alongside the ICPG. Gateway Health Plan H5932: 232 of 286 sampled enrollee-years had unsupported diagnosis codes. 81 percent unsupported. $830K net overpayment on the sample alone, before extrapolation.

This week: map every HCC capture workflow against the named-and-shamed practices in the ICPG. Document the clinical decision making, not just the code.

04Star Ratings overhaul: 11 measures removed, HEI shelved, +$18.6B to plans.

On April 2, in the CY 2027 MA/Part D Final Rule, CMS finalized removal of 11 Star Ratings measures (administrative-process measures with little plan variation). CMS chose not to implement the Excellent Health Outcomes for All reward (formerly Health Equity Index). The historic reward factor stays. CMS added a new Part C Depression Screening and Follow-Up measure (2027 measurement year, 2029 ratings).

Analysts estimate the package shifts roughly $18.6B in additional bonus dollars to MA insurers vs prior trajectory. 2026 average Star rating is 3.66. 63.5 percent of MA enrollees are in 4+ Star plans.

This week: audit your AWV templates. Add depression screening (G0444 or equivalent) by Q3 2026. Pull any HEI-dependent bonus arrangements with plans and flag them for Q4 renegotiation.

05ACO REACH sunsets December 31, 2026. LEAD Model launches January 2027.

ACO REACH ends as scheduled on December 31, 2026. CMMI confirmed no extension or expansion. CY 2026 has 74 ACOs, 125,909 providers, roughly 1.7M aligned Medicare FFS beneficiaries. The successor: the LEAD Model (Long-term Enhanced ACO Design) launches January 2027, a voluntary 10-year program designed for smaller, independent, and rural-based practices and for ACOs serving complex populations.

Separately, the CY 2026 PFS Final Rule shortened the MSSP BASIC track one-sided glide path from 7 to 5 years for agreements starting January 1, 2027. Experienced ACOs may enter BASIC Level E or ENHANCED directly. The 5,000-beneficiary minimum now only applies in Benchmark Year 3.

This week: if you've parked your practice in BASIC Levels A through B as a hedge against downside risk, the runway just got 2 years shorter. Model 2-sided risk scenarios for 2028 now.

06$7.5B in MA payments tied to HRA-only diagnoses.

OIG's April 2025 evaluation found that diagnoses reported only on HRAs or HRA-linked chart reviews, with no other 2022 service record, generated $7.5B in MA risk-adjusted payments for 2023. 1.7M enrollees affected. In-home HRAs and HRA-linked chart reviews drove almost two-thirds of that $7.5B.

OIG was explicit: either the diagnoses are inaccurate, or the enrollee did not receive needed care for documented conditions. Both interpretations support an FCA case. The Cigna $172M settlement cited "cursory in-home assessments" as the core misconduct pattern. Plans contracting in-home HRA vendors are about to pull back hard.

This week: inventory your HRA arrangements. If revenue depends on third-party HRA vendors, design the in-house transition now.

One thing worth 30 minutes this week

Pull your top 20 MA patients by visit volume. For each patient, count chronic conditions documented last year that are missing from this year's notes. That number is your missed revenue exposure. Then count captures with no downstream encounter. That number is your audit exposure. If the missed list is 4 to 7 per patient, your team is operating on V24 thinking. If no-downstream is over 10 percent of captures, your compliance team needs the ICPG on their desk by next week.