For three years, the entire Medicare Advantage risk-adjustment conversation has been about V28 — the phase-in, the lost codes, the revenue hit, the scramble to adapt. That conversation is now largely over, and it ended in a way few people expected.
MedPAC’s March 2026 report to Congress says, in effect, that V28 did its job. The more interesting question is what the data shows is driving overpayment now — because it is not primarily coding.
1. The number, and what moved it
MedPAC estimates Medicare will pay MA plans about $76 billion more in 2026 than traditional Medicare would have spent on the same beneficiaries.
That figure is large — roughly 14% above what fee-for-service would have cost. But the direction is what matters: it is lower than the prior year’s projection.
MedPAC attributes the improvement primarily to the completed phase-in of V28 and to newer risk-score data showing slower growth. The Commission has supported V28 and states plainly that the lower estimated payment difference indicates the model is having its intended effect of reducing the payment impact of coding differences between MA and FFS.
2. The split that should reframe your strategy
Coding intensity now adds about 4 percentage points. Favorable selection adds about 11.
MedPAC decomposes the gap into two drivers. Coding intensity — the upcoding story that has dominated a decade of headlines — accounts for roughly 4 percentage points in 2026. Favorable selection accounts for roughly 11.
Favorable selection is a different phenomenon entirely: enrollees whose actual costs come in below what their risk scores predict, drawn in by plan design, network structure, and benefit configuration. MedPAC notes that without these two factors, MA payments would be roughly comparable to FFS. The larger share of the problem is now enrollment dynamics, not documentation.
3. Why this does not let coding accuracy off the hook
It would be a serious misread to conclude that documentation matters less. Two things are true at once: coding intensity is a smaller share of the aggregate gap, and individual organizations still face full audit exposure for every unsupported diagnosis they submit.
Aggregate policy statistics do not protect a specific contract in a specific RADV audit. Your exposure is not the industry average; it is your own error rate. The macro story changed. Your micro obligation did not.
4. The blunt-instrument problem — and who it hurt
MedPAC commissioners raised a concern worth sitting with: V28 was an across-the-board adjustment, which means it penalized plans that were coding appropriately alongside those that were not. One commissioner described it as a very blunt tool, with smaller regional insurers among those unfairly affected.
That is the cost of correcting a system-wide problem with a system-wide lever. If you run a plan or group that documented honestly, you absorbed a correction aimed at behavior that was not yours — which is precisely why demonstrating documentation integrity is now a competitive position and not merely a compliance chore.
5. What to do with this
Three moves. Stop building your internal narrative around V28 as an ongoing crisis — the phase-in is complete and the model is stable through 2027. Redirect that attention to documentation defensibility, which is where your organization-specific risk actually lives. And if you have been coding cleanly, start being able to prove it, because the policy environment increasingly rewards organizations that can.
The strategic frame has shifted from surviving a model change to demonstrating integrity within a stable one.
Final Thoughts
The V28 era ended quietly and, by MedPAC’s account, successfully. The payment gap narrowed, and the Commission credits the model.
As someone trained as a physician who later worked in coding and audit, I read this as a genuine turning point in the conversation. The industry spent three years asking how to survive a risk-model change. The better question now is whether your documentation can withstand scrutiny in a stable model — because that is the question CMS is still asking, every year, of every eligible contract.
If your risk-adjustment strategy is still organized around surviving V28, you are fighting the last war. At HealtheNomics I help organizations shift from model-change survival to documentation defensibility — the exposure that remains once the model stops moving.
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