Sutherland Risk SigmaIQ

Risk adjustment is how CMS compensates Medicare Advantage plans based on the health complexity of their members. Accurate documentation and coding help plans receive appropriate reimbursement for the care they deliver. Under HCC Model V28, precision matters even more because qualifying diagnoses and risk weights have changed.

CMS-HCC Model V28 replaced Version 24 as the Medicare Advantage risk score model and reaches full implementation for Payment Year 2026. It removed more than 2,200 ICD-10 codes from HCC mapping and recalibrated risk weights across nearly all conditions, with CMS projecting an average 3.12% decline in risk scores industry-wide. Plans with documentation gaps are likely to feel the greatest revenue impact. Risk SigmaIQ is calibrated specifically for V28 to identify valid, high-value HCC opportunities under the current model.

A Risk Adjustment Data Validation (RADV) audit is CMS’s process for verifying that diagnosis codes submitted for risk adjustment are supported by medical records. With CMS expanding audits to all eligible Medicare Advantage contracts annually, audit readiness is critical. Every HCC submission must be backed by documentation that meets MEAT criteria (Monitored, Evaluated, Addressed, Treated). Sutherland embeds audit-ready workflows into coding and QA processes, helping ensure every submitted HCC is defensible before it reaches CMS.

Yes. Sutherland’s solution spans the full spectrum: retrospective programs (identifying missed HCCs from prior-year data), concurrent programs (real-time coding support during the current plan year), and prospective programs (identifying high-risk members for targeted outreach and care gap closure before they drive avoidable costs). Most clients begin with retrospective work to demonstrate immediate revenue impact, then expand into concurrent and prospective capabilities as the program matures.

Sutherland is designed for rapid activation. Our intake and data ingestion workflows are standardized across common data formats, and our analytics platform can begin generating prioritized member lists within weeks of data availability. Most clients see initial HCC identification reports within the first 30 to 60 days of program launch. Full program velocity, including AI-assisted coding at scale, is typically achieved within 60 to 90 days.