The Future of Risk Adjustment: Preparing for CMS Audits, Extrapolation, and AI Technology
Welcome back to Care Decoded, the podcast where we make sense of the fast-evolving world of documentation, coding, and clinical AI to power better patient care. In today’s episode, host Michael Lesnik welcomes healthcare innovation and policy leader Dr. Shannon Decker for a deep dive into the major changes facing risk adjustment as we approach 2026.You’ll hear Michael Lesnik and Dr. Shannon Decker tackle the ripple effects of a recent court ruling that vacated CMS’s RADV final rule and what that means for audit compliance, health plans, and provider groups. As the landscape shifts, they’ll explore how AI is revolutionizing regulatory oversight, the urgent need for data accuracy, and why quality and total cost of care matter more than ever in the value-based care era.This episode is packed with practical insights for health plan leaders and providers alike, including firsthand stories, strategies to shore up documentation workflows, and tips for staying competitive as technology and compliance expectations accelerate. If you want to be ready for the future of risk-based contracting and avoid common blind spots, you won’t want to miss it.Timestamps:00:00 "CMS Compliance Pause Insights"06:26 AI in Medical Data Challenges07:12 "Good Data is Essential"10:16 "Risk Adjustment Impacts Provider Groups"14:15 AI Advancements and Hiring Delay17:27 Improving Claims & Patient Care22:15 Optimize Documentation and Systems Effectively24:49 Risk Improvement Strategies31:18 Renegotiating Contracts and Data Strategy32:16 Streamlining Medical Record Management35:24 Unfair CAHPS Survey Impact41:05 Advancing Physician Support Effectively44:30 Investing for Growth and Healthcare Challenges46:13 "Thoughtful System Implementation Strategy"49:12 "Risk Adjustment: Accuracy Matters"Podcast's Website - https://caredecoded.com/ Dr. Sunil Nihalani - CEO and Founder at Inferscience - https://www.linkedin.com/in/sunil-nihalani-a6983a5/ Inferscience - https://www.inferscience.com/ Podcast Powered by TopHealth - https://tophealth.care/ “Disclaimer: Informational only. Not medical advice. Consult your doctor for guidance.”
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Moving Beyond Compliance: Building Teams for Population Health and Clinical Transformation
Welcome back to Care Decoded, the podcast where we simplify the complex world of healthcare documentation, coding, and clinical AI so we can power better care, today and for the future. In this episode, Dr. Sunil Nihalani is joined by Dr. Stella Onuoha-Obilor, a nationally recognized leader in clinical quality and population health. Her track record speaks volumes: she’s driven high-star ratings, optimized value-based programs, and built systems that put patient outcomes at the heart of performance.Together, they dive into how data leadership and human insight are converging to reshape quality and population health in the value-based era. With new CMS measures and a growing focus on health equity, it’s no longer enough to just check boxes; organizations must push beyond compliance and harness data for real clinical transformation. From bridging teams and building trust to leveraging AI and advanced analytics, Dr. Stella Onuoha-Obilor shares actionable strategies for moving from metrics to meaningful impact.If you’re curious about the future of healthcare, how technology can actually make care more compassionate, and what it takes to sustain high performance in a fast-evolving landscape, this episode has insights you won’t want to miss. Let’s decode care together.Timestamps:00:00 Redefining Quality in Value-Based Care03:48 "Whole Patient Care Focus"08:11 Personalized Care Through Data Leadership12:10 "Data Governance for Transparency"16:23 "Data Drives Healthcare Decisions"19:47 "Data Trust and Stewardship Challenges"24:05 Proactive Healthcare Through Real-Time Data26:34 People-Driven Leadership for Success28:07 "Transformational Leadership for Progress"32:29 Transforming Care: Data, KPIs, Trust35:34 "Optimizing Care, Restoring Joy"39:40 Future-Proofing Organizational Success42:44 "Proactive Healthcare Transformation"45:15 "Future of Value-Based Care"Podcast's Website - https://caredecoded.com/ Dr. Sunil Nihalani - CEO and Founder at Inferscience - https://www.linkedin.com/in/sunil-nihalani-a6983a5/ Inferscience - https://www.inferscience.com/ Podcast Powered by TopHealth - https://tophealth.care/ “Disclaimer: Informational only. Not medical advice. Consult your doctor for guidance.”
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How Provider-First Tech and Collaboration Drive RADV Audit Success
Welcome back to Care Decoded! In this episode, we dive into the second part of our RADV miniseries, shifting focus from what RADV is, to the crucial role of frontline providers in ensuring accurate, defensible documentation as part of everyday care. Host Mark McKeown is joined once again by Colleen Gianatasio, an expert in risk adjustment and value-based care with over 20 years of experience.Together, they explore why provider documentation is the foundation for RADV compliance, the biggest barriers clinicians face in meeting documentation requirements, and how the right technology, like AI-driven coding support, can help bridge the gap between compliance demands and real-world clinical practice. You’ll hear practical strategies for reducing provider burnout, cultivating a culture of accuracy, and fostering effective collaboration between plans and providers, ultimately leading to better patient outcomes and a stronger, more resilient healthcare system. Let’s keep decoding care together!Disclaimer: The opinions expressed by any participants in this podcast recording are solely their own and do not represent any organization they worked for in the past or present.Timestamps:00:00 "RAD V: Provider Role & Technology"04:08 Coding vs. Clinical Guidelines Conflict07:08 Advancing Patient Care Through Coding11:47 Optimizing Patient-Provider Time14:39 Celebrate Success, Share Best Practices17:00 Concluding RAD V MiniseriesPodcast's Website - https://caredecoded.com/ Dr. Sunil Nihalani - CEO and Founder at Inferscience - https://www.linkedin.com/in/sunil-nihalani-a6983a5/ Inferscience - https://www.inferscience.com/ Podcast Powered by TopHealth - https://tophealth.care/ “Disclaimer: Informational only. Not medical advice. Consult your doctor for guidance.”
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Building a Proactive RADV Audit Readiness Plan: People, Process, Technology, and More
Welcome to a brand new episode of Care Decoded! In this episode, host Mark McKeown is joined by renowned risk adjustment and coding expert Colleen Gianatasio to kick off a special two-part series diving into CMS’s heightened focus on RADV (Risk Adjustment Data Validation) audits. As Medicare Advantage plans face unprecedented scrutiny with CMS now pledging to audit all eligible contracts every year, the stakes have never been higher for compliance, documentation, and risk management.Together, Mark and Colleen unravel the far-reaching impact of these changes across the healthcare industry, from the increased resource demands on health plans to building a culture of compliance and leveraging people, process, and technology for audit readiness. Drawing on her expertise, Colleen shares actionable strategies for integrating risk adjustment compliance into the fabric of organizations, explains the most common pitfalls in documentation and coding, and explores how AI and prospective tools can improve audit outcomes.Whether you’re part of a health plan, provider group, or just interested in the world of healthcare compliance, this episode is packed with practical advice and insights on navigating the evolving landscape of RADV audits and value-based care. Tune in as we decode the latest industry challenges and get ready for the next episode, where we’ll dive deeper into the provider’s role in RADV success.Disclaimer: The opinions expressed by any participants in this podcast recording are solely their own and do not represent any organization they worked for in the past or present.Timestamps:00:00 Medicare Advantage Under Scrutiny06:18 Proactive RADV SWAT Strategy07:18 Continuous Provider Communication Strategy12:17 Top Coding Issues in Risk Adjustment15:29 Optimizing Risk Adjustment with Data Analytics19:34 Risk Adjustment Reporting Overhaul23:09 Prospective Risk Beats Retro AdjustmentPodcast's Website - https://caredecoded.com/ Dr. Sunil Nihalani - CEO and Founder at Inferscience - https://www.linkedin.com/in/sunil-nihalani-a6983a5/ Inferscience - https://www.inferscience.com/ Podcast Powered by TopHealth - https://tophealth.care/ “Disclaimer: Informational only. Not medical advice. Consult your doctor for guidance.”
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Closing Care Gaps and Turning Data Into Action for Better Patient Outcomes
Welcome to another episode of Care Decoded, the podcast where we break down the most pressing issues in modern healthcare. In today’s episode, host Michael Lesnik, VP of Provider Sales at Inferscience, sits down with Dr. Sunil Nihalani, CEO of Inferscience and a practicing physician, to unravel the complexities of “care gaps”, those critical yet often overlooked opportunities to improve patient care and outcomes.Drawing on over fifteen years of experience in healthcare IT and value-based care, Michael and Dr. Nihalani dive deep into why care gaps persist, the challenges providers face in closing them, and why it’s about more than just checking a box on a metric sheet. From the realities of data accuracy and insurance hurdles to the vital importance of patient communication and trust, this episode explores the human side of healthcare quality. You'll also hear firsthand strategies for closing care gaps effectively, how technology, including AI, is changing the landscape, and why these efforts matter for both health equity and patient relationships.Whether you’re a healthcare provider, a member of a clinical team, or simply passionate about better patient care, this conversation offers practical insights and fresh ideas to help you and your organization “decode” the intricacies of care gap closure.Let’s get started!Timestamps:00:00 "Optimizing Patient Care Opportunities"05:17 Patient Data and Trust Issues08:07 Patient Education on Health Screenings13:32 "Small Practice, High Ratings Success"14:18 AI's Role in Healthcare Gaps18:57 AI-Powered Care Gap Detection23:11 "Closing Care Gaps: A Holistic Approach"23:50 "Decoding Care Together"Podcast's Website - https://caredecoded.com/ Dr. Sunil Nihalani - CEO and Founder at Inferscience - https://www.linkedin.com/in/sunil-nihalani-a6983a5/ Inferscience - https://www.inferscience.com/ Podcast Powered by TopHealth - https://tophealth.care/ “Disclaimer: Informational only. Not medical advice. Consult your doctor for guidance.”
Care Decoded is the go-to podcast for clinicians, health plan leaders, and quality champions navigating the evolving world of risk adjustment, value-based care, and smarter documentation. Hosted by Inferscience, this show takes you inside the workflows, decisions, and technologies that turn clinical complexity into clarity. From demystifying HCCs and RAF scores to decoding CMS changes and exploring the impact of AI, we help you understand the data behind every diagnosis.This show isn't about theory. It's about impact. Not about compliance. But confidence. Not about more clicks. But clarity at the point of care.If you're building the future of care – one chart, one visit, one code at a time – Care Decoded is your ultimate guide.
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