The Unlinked Diagnosis Crackdown: Is Your MA Plan Ready for the CY 2027 Payment Shift?

The Centers for Medicare & Medicaid Services (CMS) has fired its clearest warning shot yet at coding practices that inflate risk scores without being tied to active patient care. The CY 2027 Medicare Advantage Advance Notice proposes a seismic shift in how risk adjustment is calculated: diagnoses from "unlinked" chart reviews will be completely excluded from payment calculations.

For any Medicare Advantage plan or risk-bearing entity, this isn't just another regulatory tweak. It's a fundamental change to the rules of the game. Organizations that have relied on aggressive chart review programs to add diagnoses without tying them to a specific patient encounter are now facing a significant, predictable revenue cliff.

The End of an Era: Linked vs. Unlinked Diagnoses

For years, MA plans have used chart reviews to find and submit diagnoses missed in initial claims data. However, CMS has drawn a hard line between two types of review records:

• Linked Records: A diagnosis that is tied directly to a specific service date or patient encounter (e.g., a doctor's visit). This is considered verifiable proof that the condition was managed. These will continue to be paid.

• Unlinked Records: A diagnosis pulled from a medical record that is not associated with a specific encounter. Think of it as a standalone code added from the chart's history without proof of current management. Starting in 2027, these will not be paid.

The rationale is simple. CMS aims to eliminate overpayments from diagnoses that may be historical or not actively managed during the payment year. The agency estimates this change alone will result in a -1.53% average reduction in MA payments, with the impact being far more severe for plans that have built their strategy around unlinked reviews.

The Problem Isn't the Review; It's the Lack of a Link

This policy change doesn't mean chart review is dead. It means that the quality and defensibility of that review are now paramount. The burden of proof has shifted. It's no longer enough to just find a diagnosis somewhere in the patient's history; you must be able to prove it was relevant to a specific instance of care.

This creates a massive operational challenge: How do you efficiently and consistently create an unbreakable link between every claim, the diagnosis, and the clinical evidence within the chart?

MedChartScan: Natively Compliant with the New Reality

This regulatory shift may be a crisis for some, but for organizations using MedChartScan, it's a validation of a workflow they already practice. Our platform was designed from the ground up to solve this exact problem.

We built MedChartScan on the philosophy that every single code must be defensible and linked to its source. Our platform was never designed to just "find codes"—it was designed to build an audit-proof case for them.

• An Unbreakable Link by Default: Our AI + Human Validation workflow inherently creates "linked" records. When a coder validates an AI-surfaced suggestion, the platform creates a permanent, immutable record connecting the final code, the specific evidence, and the certified coder who approved it.
• The Audit & Transparency Module: This isn't just a workflow; it's a core feature. Our Audit & Transparency Module was built to provide this exact "source of truth" for providers and payers, making every claim instantly verifiable against its source documentation.
• Turning Compliance into an Advantage: While others scramble to rebuild their processes, your organization can operate with confidence, knowing your risk adjustment strategy is already aligned with the future of payment integrity.

The CY 2027 proposal isn't a surprise; it's the logical conclusion of CMS's push for greater accountability. The clock is ticking for organizations built on legacy processes. For those built on a foundation of evidence-based, transparent, and linked data, the future is secure.

Don't wait for 2027 to find out your workflow is obsolete. Schedule a demo today and see how MedChartScan ensures your risk adjustment process is ready for the future.