New Insights: The Market Shift Risk-Bearing Orgs Need to React To

Why the market is shifting under risk-bearing organizations

Hospitals, health systems, and value-based care networks are standing at a crossroads and many don’t realize it yet. The combination of ACO REACH turbulence, payer reimbursement drift, and heightened CMS scrutiny is reshaping the economics of risk.

If you're still relying on legacy tooling or disconnected documentation workflows, you're already falling behind. Here's what’s changing and why now is the moment to act.

ACO REACH and MSSP Volatility: The Gap Between Winners and Losers Is Widening

The Center for Medicare and Medicaid Innovation (CMMI) released early insights from the REACH model showed that while 75% of participants earned shared savings, 25% did not. The margin between success and loss wasn’t headcount or effort, it was documentation integrity.

REACH ACOs and MSSP participants serving high-needs populations (dual eligibles, patients 85+, patients with multiple chronic conditions) saw RAF leakage because duplicate identities, chart-only conditions, and workflow misses prevented coders from seeing the full story before submission.

• Misidentification: multiple records for the same patient created attribution issues.
• Documentation gaps: conditions lived in notes but never reached the claim.
• Workflow misses: coders couldn’t access the labs, vitals, or narrative notes in time to meet submission windows.

Payer Reimbursement Model Drift: Denials Are Disguising Themselves

Leading commercial payers, including Aetna, are shifting from direct denials to “severity” reviews - a quiet form of underpayment.

Instead of rejecting claims, they reimburse less based on perceived condition severity, comorbidities or "missing" evidence. Here's what that means:

• You’re not getting zeroed out, you’re getting shortchanged.
• These "paid but underpaid" claims rarely trigger alerts inside traditional worklists.
• Without a feedback loop from 835s to the drafting experience, leakage becomes systemic, undetected, and unrecoverable without proactive tooling.

CMS Clawbacks: Audit Risk Is Now Real-Time

As CMS increases the frequency and depth of retrospective audits, the burden of proof is shifting. Providers must tie every HCC to MEAT evidence that is timestamped, encounter-specific, and reviewable at the line level.

Too many revenue integrity teams react after a clawback letter lands. By then, the burden is on you to recreate context and it’s already too late.

The Opportunity: Turn Documentation Into a Strategic Lever

This moment is not just a threat, it’s a chance to lead. Systems that can pull signals from notes, labs, vitals, and meds, enrich CPTs, and validate HCCs before submission will capture full RAF potential, detect underpayments in real time, and avoid clawbacks by submitting only audit ready lines.

Your existing tools weren’t built for this level of risk sophistication - ours is.

Next step: pressure test your process

If you’re a CFO, compliance lead, or coding director navigating value-based care, the shift is already underway. What matters now is how quickly you respond.

We help ACOs, MSOs, provider networks, and health plans fix this without burdening your EHR, changing your clinical workflow, or adding more review layers.