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The rules of health care quality are changing fast, and the biggest shift is simple to say but harder to execute. Our latest episode focuses on this fundamental shift in health care quality performance, the future of digital quality, and the multi-pronged approach organizations need to stay ahead.  Our guest, Shariff Baseer, vice president of product, quality, at Optum, unpacks what the CMS and NCQA digital quality roadmap really means for health plans, especially as STARS and HEDIS performance becomes more dependent on interoperable clinical data, eCQMs, dQMs, and IDSS total-population reporting. About Shariff Baseer Shariff Baseer is the vice president of product, quality for Optum and has almost a decade of industry experience building health care products. He specializes in quality and member engagement. Prior to his current role, he has spent time enhancing risk adjustment products focusing on advanced analytics in this area. Baseer has an MBA degree from Indiana University of Pennsylvania and engineering from VTU, India. About Optum Optum is a trusted information and technology-enabled health services business dedicated to helping make the health system work better for everyone. With more than 315,000 people worldwide, Optum delivers intelligent, integrated solutions that help to modernize the health system and improve overall population health. Click here to learn more about its risk and quality solutions.

In our latest episode, we break down the biggest findings from Reveleer's  "The State of Technology in Value-Based Care 2026," a report based on a survey of 200 senior payer and provider executives.  During this 26-minute discussion, Reveleer President and CEO Jay Ackerman weighs in on the growing gap between fast AI adoption and slow accountability. He shares what payers and providers can do now to improve governance, data confidence, and audit readiness before pressure peaks.  About Jay Ackerman Jay Ackerman is chief executive officer and president of Reveleer, where he directs the company's vision, strategy, and growth across risk adjustment, quality improvement, and clinical intelligence. He has spent more than 30  years in health care technology leadership, including prior roles as chief revenue officer at Guidance Software and senior positions at ServiceSource and WNS. He holds an MBA from NYU's Stern School of Business and a bachelor's degree in economics from Connecticut College. About Reveleer Reveleer, a health care software and services company, uses machine learning and intelligent automation technology to empower health plans control over their quality improvement, risk adjustment, and member management programs. With one transformative solution, Reveleer allows plans to independently execute and manage provider outreach and data retrieval, coding, abstraction, member management, and reporting. Reveleer leverages proprietary technology, robust data sets, and subject matter expertise, so health plans can execute programs that deliver value and improved outcomes. About the report The 2026 State of Technology in Value-Based Care report is based on a national online survey of 200 U.S.-based senior decision-makers at value-based care organizations. Reveleer collaborated with Mathematica, a policy data and analytics company, to analyze the findings. The report identifies a widening accountability gap across value-based care operations. Organizations are deploying more technology than ever before, but many still rely on manual workflows, lack confidence in their data, and lack the processes needed to validate AI-driven outputs. The findings reveal how far adoption has outpaced the governance and operational discipline required to support it.  Click here to download the report. For additional insights, listen to the Reveleer-RISE webinar, AI Governance, Audit Readiness, and the Defensibility Standard in Value-Based Care.

In this episode of RISE Radio, we share an excerpt from the April 29 RISE webinar featuring Ana Handshuh, principal at CAT5 Strategies, and Melissa Smith, founder of Newton Smith Group, as they walk through the 2027 Medicare Advantage Final Rule. This episode focuses on what Medicare Advantage plans need to know about flex card and Special Supplemental Benefits for the Chronically Ill (SSBCI) changes, including:  • Codified flex card and debit card disclosures for benefits, conditions, and limitations • Alternate pathways when members cannot use the card due to technical or non-technical barriers • SSBCI determinations that require both chronic illness criteria and benefit-level health impact rationale • Publicly posted eligibility criteria and the operational labor required ahead of January 1, 2027 To listen to the entire 75-minute webinar, including their deep dive into the Star ratings redesign, click here or visit risehealth.org to access our webinar library.

Dawn Carter, senior director of health policy and regulatory affairs at  Centauri Health Solutions, joins RISE Radio for a lively discussion on the five skills health care leaders need to succeed in value-based care, starting with how to turn analytics into decisions that actually change outcomes.  During this hour-long episode, Carter shares practical frameworks for working with data, regulations, interoperability, strategic storytelling, and social determinants of health. To learn more, see Carter in person at RISE National March 23-25 in Orlando where she will lead an interactive "Bingo" game roundtable discussion to uncover smarter strategies for risk adjustment. She'll also speak at the upcoming RISE webinar on interoperability that powers SDoH referral loop closure in value-based care on April 28 at 2 p.m. EDT. About Dawn Carter Dawn Carter, BSBA, MHA, CPC, CRC, CPMA, CDEO, CPCO, AAPC Fellow, is the senior director of health policy and regulatory affairs at  Centauri Health Solutions, with over 30 years of experience in the health care industry. She has a proven track record of success in developing innovative products and services for the Medicare Advantage, Medicaid, and commercial health plan markets and is a sought-after industry speaker and author as well as independent consultant and educator. She holds a Bachelor of Science in Business Administration and a Master of Science in Healthcare Administration and is currently pursuing a Doctorate in Business Administration and Healthcare Management. She is a member of the American College of Healthcare Executives (ACHE) and is a Fellow of the American Academy of Professional Coders (AAPC). Her extensive AAPC certifications and recent appointment to the AAPC National Advisory Board for the 2025 -2027 term further demonstrate her deep commitment to knowledge and expertise in the health care field. About Centauri Health Solutions Centauri delivers data-driven technology solutions that transform fragmented clinical and member data into actionable intelligence—maximizing accuracy, quality performance, and outcomes for health plans and health systems. Through close collaboration with our customers, Centauri improves patient and member outcomes by providing advocacy, advanced data insights, and intelligent clinical data delivery future-proofed for interoperability.

In this 20-minute episode of RISE Radio, Editorial Director Ilene MacDonald sits down with Dr. Matt Lambert, the former chief medical officer at Reveleer, to unpack the rapidly evolving landscape of Medicare Advantage risk adjustment. Together, they discuss the implications of the 2027 Advance Notice, new OIG compliance guidance, and the industry’s shift toward encounter-based, prospective risk adjustment.  Dr. Lambert explains how hybrid AI—combining generative AI with long‑standing clinical rules—can improve accuracy, reduce false positives, and streamline workflows for providers, payers, and risk adjustment teams. He also shares practical strategies for organizations beginning this transition, emphasizing partnership, user‑friendly workflows, and technology that meets clinicians at the point of care. About Matt Lambert, M.D.  Dr. Matt Lambert, is the former chief medical officer at Reveleer and a leader in health care innovation, blending clinical expertise with technology, policy, and payment strategies. He previously served as CMO of Curation Health (acquired by Reveleer in 2024) and led digital transformation at Clinovations and The Advisory Board. He has been CMIO for New York City Health + Hospitals, RWJ Barnabas, and Johns Hopkins, overseeing Epic and Cerner implementations. An emergency medicine physician for 20+ years, he authored two books on health care reform. He earned his MD from Marshall University and trained at West Virginia University.  About Reveleer Reveleer, a health care software and services company, uses machine learning and intelligent automation technology to empower health plans control over their quality improvement, risk adjustment, and member management programs. With one transformative solution, Reveleer allows plans to independently execute and manage provider outreach and data retrieval, coding, abstraction, member management, and reporting. Reveleer leverages proprietary technology, robust data sets, and subject matter expertise, so health plans can execute programs that deliver value and improved outcomes. Click here for Reveleer’s Guide to AI in Value-Based Care.

Join RISE Radio Editorial Director Ilene MacDonald for this 15-minute episode that explores how agile engagement replaces slow, campaign-centric outreach with rapid testing, hyper-personalization, and real-time learning that lower cost of care and raise member trust.  Our guest is Kathleen Ellmore, cofounder and managing partner of Engagys, a health care consumer engagement consulting and advisory services firm, who shares proof points, practical steps, and why 2026 is the moment to act. About Kathleen Ellmore Kathleen Ellmore, cofounder and managing partner of Engagys, is one of the earliest pioneers in bringing the best of consumer marketing and data-driven methodologies to health care. Instead of getting you to eat when you are not hungry and buy things you don’t need, Ellmore uses the same strategies to instead change the health equation in America.  Ellmore previously led the consumer engagement consulting practice for Welltok (formerly Silverlink) for 12 years, leveraging its data repository of over a billion consumer health interactions, the best of behavioral economics, and the latest in clinical research, to create evidenced-based communications on what works to drive consumer health care behavior yielding better outcomes and lower costs. She is often quoted in the trade and national press and is a regular speaker on the national stage, having spent the first 20 years of her career in brand marketing at leading consumer marketing organizations, including General Mills and P&G.  She also was a vice president at Digitas, a leading direct marketing firm. Recently she was selected as consultant member of the first ever FDA’s Patient Engagement Advisory Committee. About Engagys Founded in 2017, Engagys is a leading health care consumer engagement consulting and advisory services firm. With decades of combined experience in health care and having deployed hundreds of engagement and marketing projects, Engagys has driven significant value in revenue generation, consumer behavior change, and more.

In this hour-long episode of RISE Radio, Editorial Director Ilene MacDonald sits down with industry experts to break down the changes in CMS’ 2027 Medicare Advantage and Part D proposed rule, why removing 12 measures and bringing back the reward factor is a true Stars redesign, and how plans can pivot from operational wins to outcome performance. We also explore the new depression screening measure and the new SEP when providers exit networks, with clear steps to protect quality and retention. Our guests are Ana Handshuh, principal of CAT5 Strategies, Melissa Smith, founder and senior advisor of the Newton Smith Group, and Rex Wallace, founder & principal of Rex Wallace Consulting.  For more on these changes, join us at The RISE Star Ratings Master Class, December 16-18 in Frisco, Texas or RISE National 2026, March 23-25 in Orlando, Fla.

As regulatory pressures intensify and the demand for measurable ROI grows, health care organizations are rethinking how they approach risk adjustment. The landscape is shifting—from retrospective reviews to real-time, proactive strategies powered by smarter technology and deeper clinical insight. In this 38-minute episode of RISE Radio, senior leaders from Cotiviti and Edifecs share how their recent partnership is fueling a new era of innovation across the full risk adjustment lifecycle. From Medicare Advantage to Medicaid and ACA markets, they explore how scalable tech, strategic foresight, and clinical expertise are helping organizations stay ahead of compliance demands and financial pressures. About the speakers Branka Sustic, vice president of risk and quality solutions, Cotiviti, provides leadership and oversight into product and business development, client program management, and strategy to assist health plans in meeting their quality and risk adjustment goals, optimization of revenue, and risk mitigation. She is a leader with more than two decades of health care experience, blending a strong customer service and analytic foundation with experience leading change management throughout her career. Sustic is known for creating and establishing operational and support plans leading to increased client satisfaction and performance.  Dr. Summerpal Kahlon, chief medical officer at Edifecs, a Cotiviti business, works across products and functions to guide clinical strategies and policies. His career spans over 20 years of experience in diverse health care settings, businesses, and markets. Dr. Kahlon has deep expertise in value-based care and risk adjustment, and brings unique insight to help customers make the most comprehensive, informed, and clinically relevant decisions for their populations. He is a practicing physician with Veterans Affairs and an assistant professor of internal medicine at the University of Central Florida.  About Cotiviti Cotiviti enables health care organizations to deliver better care at lower cost through advanced technology and data analytics that improve the quality and sustainability of healthcare in the United States. Cotiviti’s solutions increase transparency and collaboration between payers and providers while empowering them to reduce medical and administrative costs, enable better health, improve claims payment efficiency, streamline operations, drive interoperability, and advance value-based care. Its customers serve the majority of U.S. health care consumers, providing coverage and care for over 300 million members and patients.

Medicare Advantage plans are about to face unprecedented scrutiny as the Centers for Medicare & Medicaid Services (CMS) implements a dramatically expanded approach to RADV audits. Starting in 2025, every Medicare Advantage plan will be subject to contract-level RADV audits—a significant departure from the historical approach of randomly selecting 60 plans annually.   During this 17-minute podcast, Deborah Curry, risk adjustment programs director at Medical Mutual. breaks down the critical changes that compliance teams need to prepare for immediately. She offers practical strategies for surviving this new audit environment, emphasizing the importance of designated backup personnel, weekly progress huddles, and careful oversight of vendors retrieving medical records.  Whether you're already facing a RADV audit or preparing for the inevitable, this episode provides essential guidance for navigating CMS' aggressive new approach. For deeper insights, join RISE in Tampa, Fla. on October 21-23 for the 26th Risk Adjustment Forum, where Curry will be sharing additional strategies for RADV readiness. About Deborah Curry Deborah Curry, risk adjustment programs director, Medical Mutual, joined Paramount Healthcare in May 2013 and oversees the Risk Adjustment, Coordination of Benefits, and Subrogation departments. Prior to her position with Paramount, she had 21 years’ experience working with the State of Ohio workers’ compensation program, both for the government and a contracted managed care organization. She came to Paramount with extensive knowledge in medical coding, provider billing and education, Medicare payment methodologies, quality assurance, and regulatory compliance. Curry attended The University of Toledo for both her undergraduate and graduate degrees and currently holds a Master of Business Administration with major in Healthcare Systems Management. She is an active member of the American Health Information Management Association (AHIMA) and is a Registered Health Information Administrator (RHIA) and Certified Coding Specialist, physician based (CCS-P).Curry is also an active member of the America Academy of Professional Coders (AAPC) and is a Certified Risk Adjustment Coder (CRC). She holds certificates as a Risk Adjustment Practitioner (RAP) and Advanced HCC Auditor (AHCCA and serves as a Board Member of the University of Toledo Health Information Administration Advisory Board, Health and Human Services Alumni Affiliate at The University of Toledo, and Health Information Technology Advisory Committee at Owens Community College. About the Risk Adjustment Forum RISE’s Risk Adjustment Forum is designed for leaders in risk adjustment, coding, compliance, finance, and analytics across Medicare Advantage, Medicaid, Affordable Care Act, and commercial plans.  The three-day event, which will take place Oct. 21-23 at the Grand Hyatt Tampa Bay, will tackle RADV audit ramp‑up and extrapolation, the Big Beautiful Bill Act, V28/RxHCC shifts, internal audit design, and CDI.

The Medicare Advantage (MA) landscape is shifting dramatically. With over half of all Medicare beneficiaries now enrolled in MA plans, the program faces unprecedented scrutiny from lawmakers, regulators, and beneficiaries themselves. During this 40-minute podcast, MA policy experts Carrie Graham and Neil Patil dissect the changing political and regulatory climate surrounding MA and offer crucial insights for health plans navigating these turbulent waters. They explore how the Trump administration is approaching MA reform through payment adjustments, increased oversight, and technological innovation. Graham and Patil delve into hot-button issues driving the reform conversation: prior authorization practices that frustrate both providers and patients, marketing tactics that have drawn Department of Justice attention, and the accuracy of provider directories that directly impact beneficiary access to care. They discuss key bipartisan legislative proposals gaining traction, including the No UPCODE Act and the Improving Seniors' Timely Access to Care Act. Want to learn more? Graham and Patil will speak at RISE West 2025, the Medicare Advantage senior leadership event of the year, August 25-27, at Paris Las Vegas. Also check out additional information from the Medicare Policy Initiative blog posts, publications, tools, and resources, including a compendium of Medicare Advantage policies and a comparison tool of legislation that's been rumored to be included in a potential end-of-the-year legislative package (the Improving Seniors Access to Timely Care Act) and CMS regulations. Carrie Graham, Ph.D., is a research professor and the director of the Medicare Policy Initiative at Georgetown University’s Center on Health Insurance Reform (CHIR), where she oversees a portfolio of policy analysis, research, and technical assistance for policymakers on Medicare Advantage and original Medicare. Previously she was the director of aging and disability policy at the Center for Health Care Strategies. She also holds an adjunct professor appointment at the University of California, San Francisco, Institute for Health and Aging. Neil Patil, MPP, is a senior fellow and the policy director at the Medicare Policy Initiative at CHIR, where he conducts policy analysis and provides technical assistance to policymakers on Medicare Advantage issues. Prior to joining CHIR, he was a senior analyst at the Centers for Medicare & Medicaid Services Office of Legislation, where he provided technical assistance to Congress on issues related to Medicare Advantage and the Medicare Drug Price Negotiation Program. In this role, he served as the lead analyst on Medicare Advantage issues.

Welcome to the latest episode of RISE Radio, our podcast series that focuses on issues that impact policies, regulations, and challenges faced by health care professionals responsible for quality and revenue, Medicare member acquisition and experience, and/or social determinants of health. Special thanks to DUOS for sponsoring this episode, which features Ana Handshuh, principal of CAT5 Strategies, and Jenn Kerfoot, chief strategy and growth officer, DUOS, discussing the impact of the election on Medicare Advantage and the potential changes ahead under President-elect Donald Trump’s nominees: Robert F. Kennedy Jr. as HHS secretary and Dr. Mehmet Oz as CMS administrator. During this 55-minute podcast, they discuss the overall outlook for Medicare Advantage, as well as regulations that address marketing practices, prior authorization, Star ratings, health equity, and social determinants of health. About Ana Handshuh Ana Handshuh, principal at CAT5 Strategies, is a government programs executive with expertise in creating and implementing corporate programs for the health care industry. Her background includes quality, core measures, care management, benefit design and bid submission, accreditation, regulatory compliance, revenue management, communications, community-based care management programs and technology integration. She is a sought-after speaker on the national health care circuit in the areas of quality, Star ratings, care management, member and provider engagement, and revenue management. About Jenn Kerfoot Jenn Kerfoot, chief strategy & Growth officer, DUOS, is a visionary health care leader with deep expertise in Medicare Advantage and value-based care. Kerfoot leverages her extensive background in health care policy, regulation, and business development to drive strategic growth and innovation at DUOS, developing tailored solutions that meet the evolving needs of Medicare Advantage plans. A seasoned podcast host, Kerfoot regularly explores critical issues like the looming threat of Medicare insolvency, the challenges of financing care for an aging population, the impact of rising health care costs, and disparities in care access. With previous leadership roles at FarmboxRx, Excelera Health, and NationsBenefits, Kerfoot has a proven track record of navigating complex health care regulations and aligning strategies with market demands. Beyond her executive role, she is a recognized thought leader and advocate for progressive health care practices, advising venture capital and private equity firms on investments in transformative health care solutions. Kerfoot’s pragmatic optimism and relentless problem-solving approach are key to her success in fostering collaboration and pushing the boundaries of what’s possible in health care. About DUOS DUOS is a health care technology company building solutions to improve plan performance and enhance the continuum of care. Our AI-powered digital experiences match social determinants of health (SDoH) and care navigation needs with more than 100,000 Medicare benefits, community resources and government programs to improve health outcomes and beneficiary satisfaction and close gaps in care.

Join us for the latest episode of RISE Radio, our podcast series that focuses on issues that impact policies, regulations, and challenges faced by health care professionals responsible for quality and revenue, Medicare member acquisition and experience, and/or social determinants of health. Katie Devlin, DHSc, MS, CPHIMS, vice president of interoperability at Cotiviti, returns to RISE Radio and is joined by Adam Gilbert, director of interoperability operations and partnerships at Cotiviti, for this 23-minute episode. They discuss the latest regulatory requirements, what to expect for 2025, challenges, and best practices to implement a robust digital data strategy. About Katie Devlin Katie Devlin, DHSc, MS, CPHIMS, vice president, interoperability, Cotiviti, Inc. is responsible for creating an enterprise-wide health data exchange strategy to address clients’ unique business needs while reducing provider abrasion, maintaining regulatory compliance, and optimizing value. She oversees all initiatives related to digital health data acquisition, ingestion, storage, and normalization, including the expansion of Cotiviti’s electronic health data networks and strategic partnerships. Drawing on her extensive informatics and health information exchange experience, she is an advocate for ensuring health information is delivered in a way that enhances the member, provider, and payer experience. About Adam Gilbert Adam Gilbert, director, interoperability operations and partnerships, works collaboratively with payers, providers, and vendors to increase the use of clinical data exchange. With over 20 years of experience in health care operations and consulting, He is committed to enhancing the health care landscape through effective interoperability strategies and operational excellence. Prior to joining Cotiviti, he held senior management roles at Change Healthcare and McKesson.  About Cotiviti Cotiviti enables health care organizations to deliver better care at lower cost through advanced technology and data analytics, helping to ensure the quality and sustainability of how health care is delivered in the United States. Cotiviti’s solutions are a critical foundation for health care payers in their mission to lower health care costs and improve quality through higher performing payment accuracy, quality improvement, risk adjustment, consumer engagement, and network performance management programs. The company also supports the retail industry with data management and recovery audit services that improve business outcomes.

During this 20-minute podcast, Melissa James, senior consultant at Wolters Kluwer, Health Language, provides insight into RADV audits for coders, auditors, coding managers, senior leaders, chief financial officers, and chief executive officers. She discusses the latest news; technology, such as AI, that can assist Medicare Advantage organizations with audit preparation and project management; and the best strategies to prepare for audits. About Melissa James Melissa James, CPC, CPMA, CRC, risk adjustment SME, senior consultant, Wolters Kluwer, Health Language, supports the company's Health Language solutions with content maintenance. She has more than 20 years of health care experience in coding, risk adjustment, billing, physician and coder education, accounts receivable management, regulatory and compliance, and consulting. She received her associate degree from Pueblo Community College. About Wolters Kluwer Wolters Kluwer provides trusted clinical technology and evidence-based solutions that engage clinicians, patients, researchers, and the next generation of healthcare providers. With a focus on clinical effectiveness, research and learning, clinical surveillance and compliance, as well as data solutions, our proven solutions drive effective decision-making and consistent outcomes across the continuum of care.

Dawn Carter,  director of product strategy at Centauri Health Solutions, joins us for the latest episode of RISE Radio, our podcast series that focuses on issues that impact policies, regulations, and challenges faced by health care professionals responsible for quality and revenue, Medicare member acquisition and experience, and/or social determinants of health. In this 23-minute podcast, recorded on April 18, Carter discusses the shift from the V24 to V28 risk model, the coding changes, and its risk adjustment applications.  About Dawn Carter  Dawn Carter, BSBA, CPC, CRC, CPMA, CDEO, CPCO, CSPO,  is a director of product strategy at Centauri Health Solutions. Her career in health care spans 25 years, which most recently includes extensive experience in developing revenue integrity and quality software solutions, with a focus on encounter management and risk adjustment solutions for Medicare Advantage, Medicaid, and Commercial health plans.  She also provides strategic advisory solutions and consulting services for revenue cycle operations. Prior to that, her experience spans all domains of health care including health plan claims and provider systems administration, and healthcare applications development. Her experience also includes multiple teaching engagements in medical administration, billing, and coding. Carter holds a bachelor’s degree in business administration. She is a passionate and prolific industry speaker, author, blogger and subject matter expert in claims, EDI management, and risk adjustment.   About Centauri Health Solutions  Centauri Health Solutions is a leading provider of technology-enabled analytics and services helping health plans and health systems to manage their variable revenue linked to population health (risk), quality, and eligibility factors. These efforts result directly in better-informed health care delivery, richer benefits, and reduced out-of-pocket healthcare costs for the members and patients they serve.

Welcome to the latest episode of RISE Radio, our podcast series that focuses on issues that impact policies, regulations, and challenges faced by health care professionals responsible for quality and revenue, Medicare member acquisition and experience, and/or social determinants of health. Our guests are Ana Handshuh, principal of CAT5 Strategies, Melissa Smith, founder and senior advisor of the Newton Smith Group, and Rex Wallace, founder & principal of Rex Wallace Consulting.  During this 70-minute podcast, they discuss the major changes in the 2025 Medicare Advantage Final Rule that the Centers for Medicare & Medicaid Services released on April 4. The conversation delves into the Medicare Advantage marketing changes, including supplemental benefits and compensation to MA brokers and agents; dual eligible special needs plans (D-SNPs); network adequacy standards; Star rating measures; and strategies for compliance.  For more on these changes, check out RISE’s upcoming spring conferences: Special Needs Plan Leadership Summit, May 1-3 in New York City Risk Adjustment Forum, May 20-22 in New Orleans Qualipalooza 2024, June 2-4 in Atlanta