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 Challenges
07:12 "Good Data is Essential"
10:16 "Risk Adjustment Impacts Provider Groups"
14:15 AI Advancements and Hiring Delay
17:27 Improving Claims & Patient Care
22:15 Optimize Documentation and Systems Effectively
24:49 Risk Improvement Strategies
31:18 Renegotiating Contracts and Data Strategy
32:16 Streamlining Medical Record Management
35:24 Unfair CAHPS Survey Impact
41:05 Advancing Physician Support Effectively
44:30 Investing for Growth and Healthcare Challenges
46:13 "Thoughtful System Implementation Strategy"
49:12 "Risk Adjustment: Accuracy Matters"
Navigating the Future of Risk Adjustment, Compliance, and AI in Healthcare
In the latest episode of Care Decoded, key insights were shared by healthcare industry experts Michael Lesnik and Dr. Shannon Decker about the rapidly evolving landscape of risk adjustment, regulatory compliance, and artificial intelligence (AI) in clinical documentation. If you want to understand what 2026 has in store for provider groups, health plans, and the future of audits, this episode is a must-listen. In this blog, we’ll break down the essential takeaways and offer practical tips to help industry professionals prepare for what’s ahead.
The Impact of Recent RADV Court Rulings on Compliance
Recently, a federal judge vacated the CMS RADV (Risk Adjustment Data Validation) final rule regarding extrapolation, which had significant implications for billions in government clawbacks. However, as Dr. Shannon Decker emphasizes, this isn't the end of the compliance story. She describes the ruling as more of a temporary pause than a full stop. Dr. Shannon Decker warns that everyone needs to stay vigilant, as CMS is expected to revisit the rule or introduce new measures soon. The focus on compliance is not going away. Healthcare organizations should use this opportunity to get their documentation and records in order to better withstand whatever changes might be on the horizon.
AI and Technology: A Double-Edged Sword for Audits
The role of AI and technology in risk adjustment audits is accelerating. Dr. Shannon Decker expresses concern about overreliance on technology, noting that while tools like AI can help, they’re not foolproof. Current AI accuracy rates for medical record audits are estimated at sixty to seventy percent and still require human oversight. The real key is ensuring foundational data quality. Without clean and precise data, technology will only amplify existing errors.
Health plans and provider groups must focus on establishing robust data management practices before integrating advanced tech solutions. Exercise critical thinking and analytical review even after adopting AI systems, and never blindly trust the output.
Regulatory Acceleration and the Need for Proactive Preparation
CMS had ambitious plans to audit all health plans annually and retroactively clear audits from previous years. Even with the court’s intervention, Dr. Shannon Decker expects that timeline to be only marginally delayed. Improvements in AI will enable CMS to catch up rapidly. Audits could easily expand to 100 percent record auditing as technology evolves.
The pressure is on for health plans and providers alike to stay audit-ready at all times. This means not only meeting risk adjustment and compliance standards but also actively investing in data infrastructure and processes.
Documenting for Value-Based Care: Provider and Health Plan Priorities
For health plans, failing to keep pace with risk adjustment accuracy requirements can be costly. Dr. Shannon Decker points out that focusing only on risk adjustment is not enough. Quality measures and total cost of care are increasingly important metrics. Providers need to assess and upgrade their systems, ensure EMRs transmit the full range of diagnosis codes, and close care gaps proactively.
For provider groups, this also means regularly training physicians to document to the highest specificity and leveraging both technology and human resources to optimize workflows. Having a clear, centralized data repository makes defending against audits much easier, as illustrated by stories shared during the episode.
Avoiding the Most Common Blind Spots
The main blind spot identified by Dr. Shannon Decker is data management. Many organizations overestimate their ability to access complete and clean records when needed. Providers still working with paper charts or out-of-date EMRs are particularly vulnerable. Regular audits of internal systems and processes, ensuring signatures and dates are present, and properly closing notes are critical steps.
Actionable Steps for 2026 and Beyond
Review Contracts: Make sure risk contracts are up to date and reflect your capacity to succeed in today’s environment.
Centralize and Audit Data: Centralize data storage and routinely audit for cleanliness and accessibility.
Strengthen Networks: Build better relationships with specialists and hospitals for both patient care and data sharing.
Invest in Training and Support: Both technology and staff training will be critical to success.
Managing Burnout as Compliance Pressure Grows
Physician burnout is a real concern as compliance demands increase. Dr. Shannon Decker suggests solutions like improving workflows, hiring extenders or scribes, and open dialogue between health plans and providers to ensure support translates into real, practical changes.
The Strategic Priority for Survival
The future of risk adjustment, coding, and audit compliance is not just about ticking regulatory checkboxes. As Michael Lesnik notes, it’s about strategic survival in a world quickly shifting toward value-based care. Healthcare leaders who double down on data, collaboration, and thoughtful adoption of technology will be far better equipped to thrive in tomorrow’s regulatory environment.
Stay tuned to Care Decoded for more expert insights on future-proofing your healthcare organization.
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.”