A couple of weeks ago, the Creyos team ventured to Las Vegas for RISE West 2025 alongside more than 500 diverse voices and senior leaders from policy, health plans, and provider organizations; each voice bringing with them their unique perspective on a program evolving faster than ever before: Medicare Advantage (MA).
With every session I attended, my curiosity grew. If change is this rapid, how do we ensure the system grows in the right direction? And as I listened further, the answer became surprisingly clear: the future of Medicare Advantage is built on three core principles: accountability, transparency, and, most importantly, patient-centered care.
These aren’t just themes; they’re hallmarks for the future of healthcare.
With that in mind, here are some of our team’s key insights and perspectives from RISE West 2025—perspectives we’ll be paying close attention to as Medicare Advantage continues to evolve.
Key Takeaways:
|
Payment and Risk Adjustment |
With the V28 risk adjustment model fully phased in by 2026, CMS is tightening the rules around coding. |
|
Transparency and Beneficiary Protections |
CMS is strengthening reporting requirements for supplemental benefits and requiring provider directory verification every 90 days. |
|
Prior Authorization and AI Guardrails |
CMS rules, aligned with provisions in the Improving Seniors’ Timely Access to Care Act, are pushing for electronic prior authorization, more reporting, and new enrollee protections. |
|
Financial Pressure on Providers |
MA payments to plans are projected to increase by $35 billion in 2026, but fee-for-service provider payments will only rise by 2.5%. |
How Medicare Advantage is Evolving
Payment and Risk Adjustment Changes
When it came to risk adjustment, one message came through loud and clear: compliance expectations are tightening. With the V28 model scheduled to be fully phased in by 2026, Centers for Medicare & Medicaid Services (CMS) is making it clear that diagnoses submitted without sufficient clinical documentation will likely face increasing scrutiny.
Speakers underscored that conditions identified through standalone health risk assessments (HRAs) alone or retrospective chart reviews may be unlikely to pass muster moving forward. The concern is accuracy; RAF scores lose credibility when unsupported codes inflate risk. As CMS pushes for stronger guardrails, every diagnosis will need audit-ready substantiation and evidence of clinical engagement.
The conversation also touched on the proposed No UPCODE Act, which would block payments for diagnoses recorded solely through short surveys or one-off check-ins not tied to treatment. While intended to curb gaming, speakers raised concerns that it could also discourage legitimate home-based care if not carefully defined.
Adding to the pressure, CMS is expanding RADV audits with new technology and automation, signaling an end to the era of small sample reviews. The shift means broader oversight across organizations, and for health plans and providers, the takeaway from RISE was clear: documentation, thorough assessments, and clear evidence of follow-up care aren’t just best practices—they’re becoming the expected standard.
Increasing Transparency and Beneficiary Protections
Industry leaders also made it clear that CMS is looking more closely at beneficiary protections through data transparency. One insight continually repeated: provider directories must be accurate, verified, and updated every 90 days.
Attendees noted that too many beneficiaries still find themselves in situations where a provider is listed as in-network but isn’t actually available. The strengthened reporting requirements for supplemental benefits follow the same logic—patients should have a clear, accurate picture of what benefits they’re entitled to. For plans and providers, the takeaway was unmistakable: defensible, accurate data isn’t just about compliance, it’s about ensuring trust and accountability across the system.
Prior Authorization and AI Guardrails
Another key topic discussed was prior authorization reform. CMS, in step with the Improving Seniors’ Timely Access to Care Act, is moving toward electronic prior authorization, greater reporting, and stronger enrollee protections.
Event speakers also pointed to new guardrails on the use of AI in utilization management, with regulators stressing the need for transparency and auditability of algorithms. The takeaway was clear: accountability and transparency are becoming embedded expectations in how prior authorization is managed.
Financial Pressure on Providers
One of the big numbers that caught attention at the conference: Medicare Advantage payments are projected to jump by $25 billion in 2026, while fee-for-service provider payments will only inch up by 2.5%. That gap is expected to reshape contracting conversations and put even more weight on delivering measurable outcomes—both clinical and financial.
For smaller and independent practices, this shift is especially tough. Limited resources make it harder to keep pace with new documentation and compliance demands. As a result, many are finding themselves pulled toward larger networks, where the infrastructure to support value-based care is already in place—even if it means giving up some independence to manage the growing administrative load.
How Creyos Helps Providers Stay Ahead of Industry Changes
Between the looming No UPCODE Act and other industry scrutiny, it is clear that surface-level coding will no longer suffice—diagnoses must be tied to real, documented care. This shift highlights how essential it will be for providers to back up diagnoses and risk adjustment with objective, patient-centered evidence. That’s exactly where Creyos supports health systems today.
Defensible Risk Capture with Objective Data
Healthy systems can integrate Creyos digital cognitive assessments directly into Annual Wellness Visits and routine care. By capturing conditions like dementia at the point of care—rather than through retroactive chart reviews or HRAs—providers can generate clinically relevant and audit-ready documentation that will remain compliant with evolving regulations.
Equity and Consistency
Because Creyos uses standardized, science-backed tasks validated by decades of peer-reviewed research, patients are evaluated objectively. With its remote administration, Creyos is accessible to more diverse patient groups while ensuring consistent and equitable assessment workflows. This reduces the risk of variability and disparity, ensuring that risk capture is not only defensible but equitable.
Meaningful Clinical and Financial Impact
Health systems adopting Creyos have seen dementia capture rates increase by up to 300%. This aligns RAF scores with true population prevalence while supporting earlier intervention, better outcomes, and more sustainable value-based performance.
Walking away from RISE West, I was reminded that while the Medicare Advantage landscape is becoming more complex, this growing complexity also creates opportunity. The demand for transparent, defensible coding and follow-up care presents the opportunity for providers, large and small, to rise to the occasion, provide the best quality care, and improve their documentation to best represent the complexity of the conditions that they treat.
