Health Plans Brace for 2026: A Shift to Proactive Risk Adjustment Strategies
Health plans are undergoing a significant strategic overhaul as they prepare for evolving regulations and audit methodologies in risk adjustment, a process critical for ensuring financial sustainability and accurate healthcare reimbursement. The changes, anticipated to take full effect in 2026 and beyond, are prompting a move away from solely relying on retrospective data analysis toward more proactive, concurrent, and prospective approaches.
The industry is responding to these pressures by investing in advanced technologies and refining their operational strategies. According to a recent announcement, senior leaders from Cotiviti and Edifecs shared insights on building scalable risk adjustment technology initiatives during a recent episode of the RISE Radio podcast.
“Regulatory changes and evolving audit methodologies are forcing health plans to rethink their approach,” one analyst noted. “The focus is now on preventing errors before they impact revenue and compliance.”
The podcast featured Branka Sustic, Vice President of Risk Adjustment and Quality at Cotiviti, and Summerpal Kahlon, M.D., Chief Medical Officer at Edifecs. They outlined key strategies for navigating this complex landscape, including:
- Enhancing Data Accuracy: Improving the quality and reliability of patient data is paramount.
- Aligning Tech Investments: Ensuring technology investments deliver measurable improvements in risk scores and revenue.
- Building Integrated Strategies: Creating a cohesive approach to risk adjustment that spans the entire healthcare lifecycle.
The collaboration between Cotiviti and Edifecs is positioned as a driving force in this next wave of innovation, offering solutions across the entire risk adjustment lifecycle. A new checklist released alongside the podcast provides a concrete action plan framework for both short- and long-term success, along with critical Key Performance Indicators (KPIs) to track and improve impact. [Placeholder for a chart illustrating the impact of prospective risk adjustment on revenue.]
Expertise Driving the Change
Branka Sustic brings over 20 years of healthcare experience to her role at Cotiviti, focusing on product and business development, client program management, and strategic initiatives designed to optimize revenue and mitigate risk for health plans. She is recognized for her ability to establish operational and support plans that demonstrably improve client performance.
Dr. Summerpal Kahlon, with a similarly extensive 20-year career spanning diverse healthcare settings, leverages his deep expertise in value-based care and risk adjustment at Edifecs. Currently a practicing physician with Veterans Affairs and an assistant professor of internal medicine at the University of Central Florida, Dr. Kahlon provides clinical guidance to shape the company’s strategies and policies.
“The combined strengths of Cotiviti and Edifecs are uniquely positioned to help health plans succeed in this evolving environment,” a company release stated.
As prospective and concurrent risk adjustment become increasingly vital, health plans are urged to proactively adapt their strategies to remain competitive and compliant. The resources offered by Cotiviti and Edifecs provide a roadmap for navigating these changes and achieving long-term success.
