How Medicare Advantage Plans Build Risk Stratification Pipelines for Care Management

Medicare Advantage plans use risk stratification pipelines to score and rank members by clinical and financial risk, directing care management resources to those who need them most. The approach combines a stable, explainable base signal — the CMS-HCC V28 Risk Adjustment Factor — with supplemental data such as emergency visits, inpatient stays, and care gaps. Members are sorted into tiers like stable, rising-risk, high-risk, and catastrophic, with the rising-risk tier considered especially valuable due to unresolved documentation and care gaps. Explainability is a key design requirement, as care managers and auditors must be able to understand and trust the scoring logic. The pipeline is intended to generate actionable work items, linking clinical outreach directly to documentation accuracy and revenue integrity for the plan.