Medicare Advantage Chart Retrieval Is at an Inflection Point. Here’s What Plans Should Do About It

V28 is fully phased in. RADV audits are quarterly. Audio-only and unlinked CRR diagnoses are out. The plans that modernize retrieval now will protect both their risk scores and their audit posture.

For Medicare Advantage plans, 2026 is the year chart retrieval stops being a back-office function and becomes a strategic discipline. Three forces are converging at once — and they all point in the same direction.

Three forces, one playbook

Retrieval is no longer a year-end project. Leading MA plans are treating it as a continuous capability that supports risk adjustment, care management and audit readiness throughout the year.

V28 is fully in effect. The CMS-HCC V28 risk adjustment model now governs 100% of MA risk score calculations for payment year 2026. The model reduces valid ICD-10-CM diagnostic codes from 9,797 to 7,770 and expands hierarchical condition categories from 86 to 115. CMS projected an average risk score reduction of about 3.12% under V28 versus V24. Translation: given the reduction in model HCCs, the importance of capturing every accurately documented diagnosis code has increased.

Enforcement is escalating. It’s important to note that the quarterly audit cadence is temporary and applies only to CMS’s catch-up effort. As part of this initiative, CMS has expanded RADV audits from a limited subset to all RADV-eligible Medicare Advantage contracts annually, with new audits initiated quarterly during the catch-up period. The OIG issued its first MA-specific compliance program guidance since 1999 in February 2026, explicitly naming risk adjustment as a primary enforcement concern. The DOJ-HHS False Claims Act Working Group, formed in July 2025, lists MA fraud as a priority area — backed by $6.8 billion in FY 2025 FCA recoveries.

Digital infrastructure has matured. TEFCA has moved from emerging framework to broadly adopted standard, with multiple QHINs operational and onboarding payers at scale. The CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) requires MA organizations to implement Patient Access, Provider Access and Payer-to-Payer FHIR APIs by January 1, 2027. The infrastructure to retrieve records digitally, at scale, finally exists.

The plans that pull these three threads together will lead. Those who don’t may find themselves under-coded, over-audited or both.

What modernization actually looks like

1. Start retrieval early, run it continuously

The annual Q4 chart-chase is over. Leading MA plans treat retrieval as a year-round process, with multiple waves: an early member-based release after eligibility stabilizes in February, a mid-year sweep for high-risk members, and a late Q3 / early Q4 sweep before submission. Early retrieval distributes provider outreach across the year, captures diagnoses in time for the September sweep, and surfaces uncontrolled conditions early enough for care management to intervene.

2. The most effective retrieval strategies combine provider-centric retrieval for known providers with member-based retrieval to uncover diagnoses across a member’s full care continuum

Traditional retrieval is organized around providers — chase the PCPs and specialists you know about, hope you don’t miss anything. Member-based retrieval flips the model: identify the member, and retrieve records from across their full care continuum using digital networks.

The results justify the shift:

• One pilot expanding retrieval beyond known providers to the member’s broader care network yielded a 16% increase in previously documented but unsubmitted HCCs
• A large plan project retrieved 2 million charts across 1.5 million members using a digital member-based strategy, achieving an 18:1 ROI
• Advanced digital exchange projects consistently deliver ~80% of charts within 14 days, with the balance arriving in under 30 days

Member-based retrieval also reduces provider abrasion — one query returns many records, instead of dozens of duplicative requests hitting the same offices.

3. Adapt to V28 with precision

V28 demands more granular, better-documented diagnoses. Conditions that previously rolled into broad HCCs now require specific ICD-10-CM codes backed by detailed clinical documentation. Retrieval programs must recalibrate targeting logic, suspecting algorithms, and coder training to reflect the new HCC landscape — and stop relying on historically high-yield HCCs that have been eliminated or reclassified.

4. Respond to the 2027 Rate Announcement now

Two changes have direct operational consequences:

• Beginning with PY 2027, CMS will no longer use diagnoses from audio-only telehealth encounters in Medicare Advantage risk score calculations. As a result, retrieval programs should not pursue or submit diagnoses sourced solely from audio-only visits.
• Unlinked Chart Review Record (CRR) diagnoses are excluded from risk score calculation. All chart-review-derived HCCs must be linked to a qualifying encounter. (Exception: unlinked CRRs are retained for beneficiaries switching between MA organizations — a benefit for high-growth plans.)

Both changes raise the bar for member-based retrieval: complete, encounter-linked records win.  

5. Treat compliance as continuous, not periodic

During CMS’s RADV catch-up period, quarterly audit initiations underscore the importance of ongoing audit readiness. Early medical record retrieval gives plans more time to validate coding accuracy, remediate unsupported diagnoses, conduct internal and vendor audits, and maintain the documentation needed to support every submitted HCC.

Why partnerships matter

Few health plans can build and maintain broad interoperability connections on their own. Partnering with vendors that already maintain EMR, HIE, data aggregator, and TEFCA integrations reduces complexity while improving chart yield and retrieval speed.

The path forward

The opportunity to capture risk accurately has never been greater—and the cost of getting it wrong has never been higher. Plans that embrace continuous retrieval, digital exchange, member-centric data strategies, and audit-ready coding will be best positioned for what’s next.

Want the full picture? Download the white paper, Optimizing Chart Retrieval: Early Retrieval, Digital Exchange, and Member-Based Approaches, or visit datavant.com to connect with our team.