Major regulatory forces, from RADV extrapolation to new payment models, are converging. Here is why the next 18 months represent the most significant operational transformation in a decade.
The Medicare Advantage sector is facing its most significant operational transformation in a decade. We are no longer looking at isolated policy tweaks; instead, a simultaneous convergence of aggressive enforcement, audit restructuring, and payment modernization is creating a completely new baseline for performance.
We have reached a critical inflection point. Organizations that treat this era as “routine” will find themselves operationally disadvantaged as CMS systematically moves toward outcome-based measurement and technology-enabled compliance.
At ATTAC Consulting Group, our latest whitepaper analyzes these converging forces. The conclusion is clear: the strategic imperative is immediate action.
The Pillars of the Shift
The upcoming changes signal a move away from “check-the-box” documentation and toward outcome-based measurement, technology-enabled compliance, and aggressive enforcement.
1. The Audit “Culture” Shift
For 2026, CMS is fundamentally changing how it audits plans. The era of “scoring” is over. The new protocols eliminate scoring in favor of classifications (CAR, Observation, or IDS) and integrate Compliance Program Effectiveness directly into program area discussions.
This is a signal that CMS values integrated compliance thinking over structural documentation. Plans that treat compliance as a reactive exercise will face complex Corrective Action Requirements (CARs) requiring independent validation, while those with robust monitoring will see simplified requirements.
2. Star Ratings: Simplification is Not Relaxation
The 2027 Proposed Rule removes 12 administrative measures and adds a new Depression Screening measure. While “simplification” sounds beneficial, it actually raises the stakes. This change creates clear winners and losers: plans with mature behavioral health integration will gain a competitive advantage, while those relying on retired administrative measures to buoy their ratings will struggle.
3. The Return of RADV Financial Risk
Perhaps the most immediate financial threat is the RADV appeal. CMS is appealing the Fifth Circuit ruling that vacated their extrapolation authority.
If CMS wins, extrapolation could apply retroactively to PY2018 audits. This signals an aggressive stance on overpayment recovery. Plans cannot afford to wait for the appeal outcome; you must operate as if extrapolation will return and accelerate deletion programs for unsupported diagnoses immediately.
4. New Payment Models & Modernization
Finally, we are seeing a distinct move toward outcome-aligned payment. CMS has acknowledged that the current risk adjustment model disadvantages smaller plans and is exploring AI-powered next-generation models.
Additionally, the introduction of the new 10-Year ACCESS Model—which pays providers for managing Medicare FFS patients using technology-supported care—signals that CMS is looking to modernize how care is delivered and reimbursed across the board. Organizations must prepare for a future where payment is strictly tied to technology-enabled outcomes rather than volume.
The Strategic Imperative: Q1-Q2 2026
The window for preparation is narrowing. The “winners” in this new landscape will be the organizations that are agile enough to deploy resources toward true health outcomes rather than just process documentation.
To help you navigate this, our new whitepaper outlines a Strategic Action Framework for Q1 and Q2 2026, including:
RADV Readiness: How to model financial exposure and conduct immediate chart-level audits.
Audit Infrastructure: Preparing compliance officers for the new quarterly CMS dialogue sessions.
Star Recalibration: Reallocating resources from retiring measures to clinical outcome initiatives.
Risk Adjustment Diversification: Monitoring signals on AI-powered models and strengthening prospective strategies.
Get the Roadmap
The 2026-2027 inflection point demands more than just regulatory interpretation: it requires proven operational execution.
Download the Full Whitepaper to access our complete analysis and the Q1-Q2 Strategic Action Framework.
Need a peer-to-peer strategy discussion? ATTAC’s Managing Director, Subbu Ramalingam, brings direct health plan executive experience to the table. As a former VP of Quality, Stars & Risk Adjustment, he has walked in your shoes. Contact us today to schedule a 1:1 strategy session.
