Rethinking Risk Coding in 2025: Why Commercial Plans Are Redefining the HIM Playbook

A Shifting Landscape for Risk Adjustment

Until recently, risk-adjustment coding was largely synonymous with Medicare Advantage (MA) plans. However, 2025 marks a decisive turn: commercial health insurers—including ACA marketplace providers and employer-sponsored health plans—are embracing risk-adjusted payment models with increasing speed.

This shift places new demands on health information management (HIM) and clinical documentation improvement (CDI) professionals, who must ensure complete, compliant documentation that reflects the full burden of patient illness in order to maintain financial stability.

How Commercial Insurers Are Changing the Rules

Risk adjustment is a reimbursement strategy that compensates payers based on a member's health status and demographics. Originally driven by CMS's MA-focused Hierarchical Condition Category (HCC) model, risk adjustment is now widely used in:

• Marketplace plans, which apply HHS-HCC models to reallocate funds among payers;
• Employer and group plans, often with custom-built risk scoring methodologies;
• Value-based programs, including capitated contracts and ACOs, where coding affects provider bonuses or penalties.

For many providers, the growing role of these models means more scrutiny from private payers, often in the form of chart reviews, queries, and compliance audits.

The Cost of Incomplete or Unsupported Coding

When chronic illnesses like COPD or advanced diabetes are under-documented—or not updated annually—risk scores fall. That decline can result in reduced payments to health plans and downstream revenue losses for providers.

At the same time, assigning diagnoses without sufficient support can trigger payer disputes or clawbacks after retrospective reviews. Coding teams must, therefore, strike a balance: document every clinically relevant diagnosis while ensuring each one is actively monitored, addressed, or treated. The MEAT (Monitor, Evaluate, Assess, Treat) criteria still serves as a foundational guideline for validating diagnosis codes under HCC models.

Why Understanding Risk Model Variations Is Essential

HIM professionals now need fluency in several parallel risk systems, each with its own logic:

• CMS-HCC vs. HHS-HCC models may classify the same condition differently;
• Proprietary payer models might apply alternate hierarchies or rules;
• Pediatric and maternity risk categories are often unique to ACA plans;
• Annual recalibrations can alter how scores are weighted or assigned.

These complexities make it vital for coding and documentation teams to stay current, particularly in multi-payer environments where accuracy directly affects reimbursement.

Modern Strategies to Navigate Commercial Risk Adjustment

To stay ahead, progressive organizations are investing in:

• Ongoing clinician education on documenting persistent or evolving conditions;
• Extending CDI beyond hospitals into outpatient and telehealth settings;
• Integrating pre-visit coding reviews that highlight missed opportunities;
• Performing internal audits to catch inconsistencies or compliance gaps;
• Collaborating across departments—especially with analytics, billing, and compliance—to track trends and forecast impact.

This integrated approach helps ensure accurate risk coding while reducing exposure to payer audits.

Leveraging Tech Without Replacing Human Oversight

Technology—including artificial intelligence and predictive coding tools—can assist in identifying documentation deficiencies and surfacing potential risk codes. However, these systems must always be paired with human validation. Coders and HIM teams must evaluate suggested codes against clinical narratives and payer rules before finalizing submissions.

Monitoring tools, such as RAF dashboards and audit tracking platforms, are now common in HIM departments, helping visualize risk trends and provider performance over time.

Final Thoughts: Risk Adjustment Is Now a Universal Imperative

Risk-adjusted coding has evolved into a fundamental element of healthcare reimbursement, affecting both public and private payer contracts. HIM and CDI teams are no longer just supporting documentation—they are central to revenue strategy and population health accuracy.

Those organizations that embrace this new reality, equip their teams with the right tools, and commit to continuous education and collaboration will be best positioned to succeed—financially and clinically—in a rapidly changing landscape.

Not Sure Where to Start?

Looking to strengthen your risk adjustment program across all payer types? Our experienced HIM and coding teams can help you stay compliant, optimize reimbursement, and support accurate population health reporting.

Click the link to learn more about our medical coding services (or) schedule a free practice-audit/ consultation today!