- What Are Risk Adjustment Companies?
- Why Risk Adjustment Matters for Healthcare Organizations
- Top Risk Adjustment Companies for 2026
- What Features Define the Best Risk Adjustment Software?
- How Does the Risk Adjustment Process Work?
- How to Evaluate Risk Adjustment Coding Companies
- Why Risk Adjustment Matters in 2026
- Frequently Asked Questions
What Are Risk Adjustment Companies?
Risk adjustment companies help health plans capture accurate patient risk scores that determine Medicare Advantage reimbursement. These organizations use risk adjustment software and clinical expertise to analyze patient data from medical records, identify HCC coding opportunities, and ensure documentation supports every diagnosis submitted to CMS.
The best risk adjustment solutions transform manual chart review into automated workflows. Traditional healthcare systems relied on processes taking 40+ minutes per record, leading to decreased efficiency and coder productivity challenges. Modern risk adjustment tools reduce this to under 10 minutes while achieving coding accuracy above 98%.
Key fact: CMS calculates 100% of risk scores using the 2024 CMS-HCC model starting January 1, 2026 [1]. This regulatory environment change means health plans must choose technology partners capable of accurate risk score calculations under the updated risk adjustment factor methodology.
Autonomous Retrospective Risk Adjustment Solution
One platform. Every HCC validated. Revenue secured.
Why Risk Adjustment Matters for Healthcare Organizations
Risk adjustment programs serve a critical function: they predict healthcare costs based on documented patient conditions. When providers accurately document a member’s medical history and relevant diagnoses, healthcare organizations receive appropriate reimbursement to cover expected care needs.
Without effective risk adjustment services, healthcare plans face several challenges. Incomplete documentation leads to understated risk scores. Risk gaps go unidentified. Financial sustainability suffers when accurate compensation doesn’t match actual patient acuity.
The risk adjustment process directly impacts patient outcomes. When risk assessment accurately reflects a member’s disease burden, organizations can allocate resources appropriately. This enables better care coordination, improved quality programs, and stronger financial performance.
For Medicare Advantage plans operating under value-based care models, risk adjustment coding determines both revenue and the ability to deliver quality care. Accurate reimbursement ensures providers have the resources to manage complex conditions effectively.
Top Risk Adjustment Companies for 2026
RAAPID: Pioneering Neuro-Symbolic AI for Risk Adjustment
RAAPID is the first risk adjustment company to deploy Neuro-Symbolic AI at scale. This breakthrough architecture combines neural network pattern recognition with symbolic clinical reasoning to solve the fundamental problem with traditional AI in healthcare: the inability to explain decisions.
Why Neuro-Symbolic AI matters for risk adjustment coding: Standard algorithms operate as opaque systems. They produce answers without showing reasoning. In risk adjustment, this creates audit risk. When CMS questions an HCC code, health plans need documented evidence trails for audit readiness, not probability scores.
RAAPID’s Neuro-Symbolic architecture integrates medical knowledge directly into its reasoning process. The system uses natural language processing to identify suspected diagnoses from unstructured data in clinical notes. It then validates each finding against clinical rules and MEAT criteria (Monitoring, Evaluating, Assessing, Treating). Every HCC includes traceable evidence linking the code to specific clinical data in the medical record.
Peer-reviewed research confirms that neuro-symbolic methods deliver superior accuracy while providing transparent decision-making [2]. This transparency supports compliance and helps risk teams maintain compliance during audits.
Key stats: 98%+ coding accuracy, 60-80% chart review time reduction, first Neuro-Symbolic AI deployed at scale for risk adjustment, HITRUST certified, automated MEAT evidence capture for RAF score optimization
RAAPID delivers risk adjustment solutions across both retrospective and prospective risk adjustment workflows, creating a single source of truth for member risk.
Cotiviti: Healthcare Analytics at Scale
Cotiviti serves more than 200 health plans, including all top 25 health plans [3]. The company combines advanced analytics with expertise to analyze patient data from billions of clinical and financial records annually.
Cotiviti’s risk adjustment services focus on healthcare analytics, payment accuracy, and quality programs. The platform uses natural language processing for medical records review and supports risk adjustment programs across MA and commercial lines. The company acquired Edifecs in 2025 to expand interoperability capabilities [4].
Key stats: 200+ payer clients, 25+ years delivering services, billions of claims data points processed.
Inovalon: Cloud-Based Risk Assessment Platform
Inovalon’s ONE Platform connects national-scale data access with predictive analytics for cloud-based risk adjustment software. The platform serves organizations representing the top 25 payers [5].
In October 2024, Inovalon launched AI-powered Converged Record Review, using algorithms to analyze patient data and reduce unnecessary manual medical records review by up to 50% [6]. The platform’s predictive modeling capabilities help document suspected diagnoses and identify risk gaps across 395 million unique lives.
Key stats: 85B+ medical events analyzed, 395M unique lives, analytics across multiple data sources.
Reveleer: Value-Based Care Platform
Reveleer provides risk adjustment software covering risk adjustment coding, quality improvement, clinical intelligence, and member management. The company raised over $65 million in 2024 funding [7].
In 2024, Reveleer processed 1.1 billion pages of medical records and delivered 2.5 million diagnoses [8]. The platform supports prospective coding at the point of care and retrospective review, with workflow automation that improves documentation quality and program performance. Reveleer serves 70+ health plans covering 66 million lives.
Key stats: 1.1B pages processed, up to 99% accuracy claimed, automation reducing review time by 42.5%.
What Features Define the Best Risk Adjustment Software?
A few essential features separate effective risk adjustment tools from outdated systems.
Explainable AI for Audit Readiness
Health plans need to understand why each HCC was suggested. Neuro-symbolic approaches provide traceable reasoning paths that support informed decision-making during audits. Platforms using traditional algorithms cannot explain their conclusions, creating compliance risk in the current regulatory environment.
Workflow Automation to Improve Accuracy
Leading risk adjustment solutions automate chart retrieval, coding queues, and quality assurance processes. This workflow automation dramatically improves accuracy while increasing productivity. Manual processes create decreased efficiency that cannot scale with growing membership.
Real Time Analytics and Predictive Modeling
Effective risk adjustment software delivers dashboards with real-time analytics that track documentation quality, flag risk, and identify gaps before submission deadlines. Predictive analytics help risk teams prioritize charts most likely to yield accurate cost predictions.
Point of Care Integration
Prospective risk adjustment captures conditions during patient encounters when clinical data is most complete. The best platforms support prospective coding at the point of care and retrospective analysis from historical medical records. This payer provider collaboration improves provider engagement while ensuring complete documentation.
How Does the Risk Adjustment Process Work?
Step 1: Data Aggregation. Risk adjustment platforms collect patient data from claims data, medical records, lab results, and clinical documentation. Systems unify fragmented sources to analyze patient data comprehensively, including medical history.
Step 2: AI-Powered Analysis. Machine learning algorithms scan collected data to identify diagnoses and find gaps. Natural language processing extracts findings from unstructured data in clinical notes. Risk assessment models predict healthcare costs based on identified conditions.
Step 3: Quality Assurance and Submission. Quality assurance processes verify every diagnosis has supporting MEAT-based clinical evidence before CMS submission. Platforms track readiness, documentation quality, and program performance in real time to optimize financial performance.
How to Evaluate Risk Adjustment Coding Companies
Ask about coding accuracy rates. Healthcare organizations need documented evidence of 98%+ accuracy. Unverified claims provide no protection.
Demand explainable AI. Ask vendors to demonstrate how their platform explains each HCC recommendation. If the AI cannot show its reasoning, it cannot support compliance requirements.
Verify productivity improvements. Effective risk adjustment services reduce chart review time by 60-80% while improving accuracy. Request specific metrics showing financial outcomes from current clients.
Confirm RAF score optimization. Every HCC needs documented clinical evidence. Evaluate how platforms capture MEAT criteria automatically to improve accuracy and ensure accurate reimbursement.
Assess expertise. Technology alone cannot replace a deep understanding of HCC coding rules and CMS guidelines. The best risk adjustment companies combine analytics with specialized knowledge.
Why Risk Adjustment Matters in 2026
The value-based care market continues to accelerate. According to the NAACOS and Innovaccer 2025 survey, 64% of organizations expect higher revenue from value-based care arrangements, with capitated models doubling since 2021 [9].
CMS has set a goal for all Medicare fee-for-service beneficiaries to be in accountable care relationships by 2030 [10]. Risk adjustment accuracy directly impacts financial sustainability under value-based care models. Health plans that capture complete risk scores receive appropriate reimbursement. Those with incomplete documentation and gaps lose revenue and face compliance challenges.
Health plans choosing risk adjustment partners in 2026 should prioritize platforms that optimize financial performance through:
- Explainable AI supporting compliance
- Documented coding accuracy above 98%
- Automation improving productivity
- Risk adjustment tools spanning retrospective and prospective programs
- Analytics delivering accurate cost predictions
Schedule a demo today and redefine your risk adjustment strategy.
Frequently Asked Questions
Risk adjustment is a risk assessment methodology that calculates patient risk scores based on documented diagnoses to predict healthcare costs. These risk score calculations determine appropriate reimbursement for Medicare Advantage and value-based care arrangements.
Neuro-Symbolic AI combines neural network algorithms with symbolic clinical reasoning. This approach delivers both accuracy and explainability, providing transparent audit trails that traditional risk adjustment software cannot match [2].
Prospective risk adjustment uses coding at the point of care during patient encounters. Retrospective risk adjustment reviews historical medical records to identify missed HCCs and address documentation gaps.
CMS calculates 100% of MA risk scores using the 2024 CMS-HCC model (V28) starting January 1, 2026, completing the three-year phase-in [1].
Accurate risk adjustment ensures providers receive accurate compensation matching patient acuity. This enables better resource allocation, improved care coordination, and stronger health outcomes for members with complex conditions.
Sources
[1] CMS, “2026 Medicare Advantage and Part D Rate Announcement,” April 2025
[2] PMC, “Explainable Diagnosis Prediction through Neuro-Symbolic Integration,” 2025
[3] Cotiviti, “About Us,” 2025
[4] CB Insights, “Cotiviti Company Profile,” 2025
[5] Inovalon, “Risk Adjustment Software,” 2025
[6] Inovalon, “Converged Record Review Launch,” October 2024
[7] Reveleer, “New Funding 2024,” 2024
[8] Reveleer, “Next Generation Risk Solution,” March 2025
[9] NAACOS and Innovaccer, “The State and Science of Value-Based Care 2025,” May 2025
[10] CMS Innovation Center, “Value-Based Care for Providers,” 2025
