Whistleblower lawsuits are pulling back the curtain on risky coding practices and costly compliance gaps in risk adjustment. From inflated RAF scores to vendor oversight failures, the consequences are real and growing. This episode unpacks several DOJ cases that reveal how coding shortcuts, unsupported diagnoses, and non-compliant queries can escalate. From internal governance gaps to coding-policy breakdowns, the message is clear: vendor oversight is a necessity.

Listen now to uncover what these cases reveal and what your plan can learn from these whistleblower lawsuits.

ABOUT OUR GUEST: 

Kristi Reyes is the Director of Risk Adjustment Coding Operations. She leads a team of 250 medical coders from various aspects of risk adjustment—including retrospective, prospective, CDI, QA, risk mitigation, and RADV. Kristi holds Certified Professional and Outpatient Coding, Risk Adjustment Coding, and Auditing certifications.

The 2026 Medicare Advantage and Part D Star Ratings are out—and they reveal more than just who earned 5 stars. Beneath the numbers lies a clear message: CMS is reshaping what quality means, shifting the balance from member satisfaction to measurable outcomes and data precision. Plans that once thrived on experience scores are now facing tougher cut points, new ECDS-only measures, and the rise of HOS as a major performance driver. 

This episode unpacks what changed, why it matters, and what payers must do now to avoid being left behind. Listen to uncover the real story behind the 2026 Star Ratings—and what it signals for 2027 and beyond.

About Our Guest: 

Shelby Jansen, Manager of Quality, Stars and Strategy, RHIA. Shelby has deep expertise in guiding payer quality strategies to meet CMS expectations, reflecting NCQA updates, optimizing Stars and HEDIS programs, and guiding health plans through digital transformation.

Navigating risk adjustment across multiple lines of business isn’t just complex, it’s a balancing act of shifting regulations, diverse populations, and evolving models. In this episode, we break down the key differences between Medicare Advantage, Medicaid, and ACA, and explain why understanding these nuances is crucial for health plans that manage all three simultaneously. Whether you’re grappling with audits, coding accuracy, or technology gaps, this conversation offers real-world insight and practical strategies for managing multiple lines of business (LOB).

About Our Guest:

Amanda Proctor has over 13 years in risk adjustment coding and specializes in risk mitigation, coding quality and education. She holds multiple certifications in coding and is an AAPC approved instructor.

What if your contact center could do more than answer questions? What if it could predict needs, detect fraud, translate languages in real time, and coach agents as they speak to members? 

In this episode, explore how AI is transforming call centers into strategic experience hubs. From agent assist tools that streamline workflows to virtual agents that replace outdated IVRs, we dig into the innovations shaping the future of member engagement. 

Think a contact center is just about answering calls? Think again. Tune in to discover how AI is reshaping member questions into a strategic advantage.

About Our Guest: 

Reinaldo Torro is an expert in modernizing member engagement with AI innovations for payer contact centers. He uses an interdisciplinary approach to enrich health plan operations using his diverse background as a frontline clinician, Master of Business Administration, Certified Lean Six Sigma Sensei, and various executive positions held with multiple payers, including Aetna, Highmark WholeCare, Coventry Health Care, and United Healthcare. 

This season on Current Trends for Payers, we’re highlighting guest experts in emerging technologies and operational strategies that health plans need to stay agile and competitive.

We’ll dig into what’s working and what’s coming next, with candid conversations from executives, product, and business leaders.

Whether you're focused on risk adjustment, member engagement, or core admin, this season offers a clear look at how forward-thinking health plans are staying ahead.

Subscribe to Current Trends for Payers on Apple, Spotify, and all major podcast apps to be the first to know when the next episode drops. 

Health plans continue to face operational delays due to fragmented systems and an over-reliance on manual reporting cycles. While data analysts work across multiple platforms to produce static reports, the insights often arrive too late to support real-time decisions. This episode explores why traditional models are no longer sustainable and how self-service dashboards, powered by a connected data ecosystem, are transforming operational agility. Listeners will hear how prebuilt metrics provide immediate visibility across functions such as claims, call center performance, and ID card fulfillment, enabling teams to respond faster, stay compliant, and enhance member outcomes. The discussion also covers adoption strategies, ROI considerations, and the organizational shift toward on-demand, decision-ready data.

Listen now to discover how leading health plans are moving from reactive operations to real-time insight, without relying on analysts.

About Our Guest: 

Michael Waxman is a health plan operations leader with over 20 years of experience as a health payer consultant at PwC and EY. He recently served as the Director of Business Operations for the post-implementation operations of a technology ecosystem for a Medicare Advantage client. Using a self-service dashboard, he ensured operational alignment for the health plan’s provider data, claims, credentialing, cross-functional alignment for call center, disputes, utilization management, and more. 

CMS has issued a major announcement that’s reshaping how Medicare Advantage plans approach risk adjustment audits. A new era of oversight is here. Defined by tighter timelines, expanded audit scope, and heightened expectations around data accuracy. Along with the announcement, a detailed compliance memo introduces new submission deadlines that demand immediate attention from health plans. This shift has wide-reaching implications for compliance strategy, resource allocation, and revenue protection.

In this bonus episode, we unpack what’s changed, why it matters, and what plans need to consider next. Listen now.

About Our Guest: 

Amanda Proctor is the Director of Coding Quality and Risk Mitigation and has over 14 years’ experience in Risk adjustment and holds multiple certifications in Coding, Auditing, and Compliance and is an AAPC Approved Instructor. She specializes in Risk Mitigation, RADV Audits, Coding Compliance and Education.

In this episode, we explore how data consolidation is reshaping health plan operations and why it is becoming essential for the future of the industry. From breaking down data silos to enabling real-time, data-driven decisions, data hubs offer health plans a scalable solution to improve efficiency and streamline processes. Discover the challenges health plans face today and how a data-centric ecosystem can unlock powerful insights, enhance member engagement, and drive cost savings. Curious how a data hub can revolutionize your operations? Tune in to find out how this technology is transforming the payer industry and why it's not just a trend but a must-have for success in 2025 and beyond.

About Our Guest: 

Adam Fenech is Vice President of Product. He has been in healthcare leadership for over 20 years, on both the payer and provider sides of the business. Adam has a degree in Computer Information Systems and has deep expertise in core administrative products and processes, as well as the emerging industry shift to a data-centric technology ecosystem model. 

Payers are seeking new ways to enhance member engagement and drive long-term retention. 

This podcast explores a powerful new-to-market strategy for transforming how health plans design member journeys to create a seamless experience in a combination of offline and online environments. 

Don’t miss the insights in this episode that will redefine how your plan approaches member engagement.

About Our Guest: 

Barb Ody is a payer consultant and expert in member experience solutions, technology and process implementations, clinical business informatics, data modeling and analysis.

Claims and enrollment management can feel like a juggling act, especially with rising volumes and the pressure to meet strict accuracy and timeliness standards. What if there were tools to simplify it all? In this episode, we dive into the game-changing power of modern workflow solutions. Discover how these tools eliminate inefficiencies, prevent cherry-picking by claims and enrollment processors, and streamline auditing, all while boosting internal team communication and productivity. Whether your health plan claims and enrollment teams are struggling with manual processes or looking to scale without adding staff, this discussion offers practical insights you can’t afford to miss. Tune in to learn how to transform your claims and enrollment management strategy!

About Our Guest: 

Alison South is the Vice President of revenue enablement and a subject matter expert in payer technology and operations. She brings 20+ years of experience in health plan operations, overseeing operational readiness, learning and development, and quality and audit operations. She has worked for large national payers running government programs, including Medicare and State Medicaid Demonstration programs and military healthcare operations.