Somewhere in your health system's patient panel right now, there are hundreds, possibly thousands, of older adults living with mild cognitive impairment or early-stage dementia who have never been screened.
They've come in for their annual wellness visits. They've had their blood pressure checked, their cholesterol reviewed, their vaccinations updated. But their cognitive health? Untouched.
This isn't a clinician failure. It isn't a patient failure. It's a systemic one. And it's playing out at an enormous scale: according to recent data, 80% of adults ages 65–80 are not receiving routine cognitive screening. Up to 61% of people living with dementia today remain undiagnosed.
The consequences aren't abstract. They show up as emergency department visits, missed opportunities for disease-modifying treatment, families in crisis without a care plan, and increasingly, as real financial exposure for the health systems and Medicare Advantage plans responsible for these patients' outcomes.
The good news: the policy environment has shifted in a meaningful way. CMS's full implementation of the HCC V28 risk adjustment model, now 100% in effect for payment year 2026, has changed the calculus for every health system and MA plan in the country. Cognitive screening is no longer just a clinical imperative. It has become a financial one.
The Scale of What We're Missing
Let's start with the numbers, because they're staggering.
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80% of adults 65–80 not receiving routine cognitive screening |
61% of people with dementia currently undiagnosed |
~11% of adults 65+ have Alzheimer's, only 4–6% are captured in diagnosis |
These stats represent the baseline reality of cognitive care in America today. The vast majority of patients who need screening aren't getting it. Not because their providers don't care, but because the tools and workflows to do it at scale aren’t good enough.
Cognitive decline is uniquely difficult to catch. Unlike hypertension or diabetes, cognitive impairment doesn't generate a number on a printout. It requires specific assessments that, until recently, were time-consuming, paper-based, and hard to fit into a 40-minute wellness visit. In fact, the standard cognitive screening tools in use today, the MMSE, Mini-Cog, MoCA, were designed between 1915 and 2006. They all predate the smartphone, the EHR, and the modern primary care visit.
The result of these inadequate tools is a care system that waits. Providers screen when patients (or their families) raise concerns. By then, years of earlier, more actionable detection opportunities have already passed.
What CMS V28 Changes And Why It Matters Now
For years, the financial incentives around cognitive care in Medicare Advantage were misaligned. Dementia was difficult to document, complex to manage, and under the old HCC V24 model, imprecisely coded. The result was a system that inadvertently discouraged thorough cognitive evaluation.
V28 changes that.
As of January 1, 2026, CMS's HCC V28 risk adjustment model is fully operative with 100% of Medicare Advantage risk scores now calculated under V28. The phased transition that began in 2024 is complete.
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What Changed in CMS HCC V28 V28 expanded HCC categories from 86 to 115, with dementia now split into three severity tiers: mild (HCC 125), moderate (HCC 126), and severe (HCC 127). Where V24 used a binary 'complicated vs. uncomplicated' classification, V28 now rewards clinical precision. The severity of a patient's cognitive impairment directly determines their risk score and the plan's reimbursement. |
This is a fundamental shift. Under V24, many providers had limited incentive to document the nuance of a patient's cognitive status. Under V28, that nuance is reimbursable, but only if it's captured correctly.
The financial stakes are real. When CMS introduced V28, it projected the model would reduce average Medicare Advantage risk scores by 3.12%, representing $11 billion in net savings to the Medicare Trust Fund in the first year of implementation alone. For many MA plans and provider organizations, conditions that once drove risk-adjusted revenue no longer do. Dementia, notably, went the other direction: the coding framework expanded, and the incentive to screen, document, and accurately classify cognitive status has never been stronger.
Meanwhile, the enforcement environment has never been more active. CMS's January 2026 RADV memorandum confirmed active audits covering payment years 2018 through 2024, with an estimated $17 billion in annual MA overpayments from unsupported diagnosis data. Organizations that are over-reporting conditions without clinical documentation face real audit exposure. But so do organizations that are under-reporting, leaving revenue on the table because cognitive impairment was never formally assessed.
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Under V28, the question isn't whether cognitive screening is worth doing. It's whether your organization can afford not to do it. |
Why Routine Screening Has Been So Hard Until Now
If the clinical and financial case for cognitive screening is this clear, why hasn't it been standard practice? The answer has less to do with will and more to do with accuracy and workflow.
Traditional cognitive assessments like the MMSE, MoCA, Mini-Cog, are administered on paper, require clinician time to score, and can take 10 to 20 minutes (minimum). In a 40-minute Annual Wellness Visit (AWV) already packed with preventive measures, there's simply no room. The result: cognitive screening gets deprioritized, deferred, or quietly dropped.
There's also a bias problem. Traditional paper tests were designed and validated on narrow demographic populations, decades ago. For patients who don't speak fluent English, who have lower levels of formal education, or who come from cultural backgrounds that affect their comfort with standardized testing, these tools can generate false positives and false negatives at alarming rates. A screening tool that systematically mislabels one population isn't just clinically inaccurate, it's inequitable. And that reduces a practitioner’s confidence in diagnosing.
And then there's what happens after the screen. Even providers who do administer a cognitive assessment often lack the structured pathway to act on it: no built-in referral workflow, no care plan documentation, no loop closed with the patient's PCP or specialist. The assessment becomes a data point without a destination.
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The V28 Documentation Standard V28 requires MEAT-based clinical evidence to support cognitive HCC codes, not just a historical mention in the record. Screening must be documented with specificity: the tool used, the score, and its clinical interpretation. Digital screening platforms that generate objective, EHR-integrated documentation are now essential infrastructure for compliant V28 coding. |
What Closing the Gap Actually Looks Like
Desert Oasis Healthcare in Palm Springs, California, provides a model worth examining. Serving a community where one in three residents is a senior, nearly twice the California state average, they integrated Neurotrack's digital cognitive screener into routine wellness visits for adults 65 and older.
The results in the first four months:
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29% increase in dementia detection rate in 4 months |
10 min average time saved per patient vs. prior workflow |
3.5% more patients identified with cognitive concerns |
These outcomes weren't achieved by adding a specialist, expanding a clinic, or increasing visit length. They came from embedding a 3-minute, device-agnostic, EHR-integrated digital screener into the existing AWV workflow. Clinicians didn't need new training. Patients didn't need a separate appointment. The results scored automatically, documented directly into the chart, and triggered next steps where needed.
The broader implication: closing the cognitive detection gap doesn't require a systemic overhaul. It requires the right tools, deployed in the right workflow, at the right point of care.
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Assessing more patients doesn't have to mean doing more work. It means doing the same work, better equipped. |
Beyond the Screener: A Cognitive Care Enablement Platform
Detecting a cognitive concern is the beginning, not the end. And this is where many screening programs and tools fall short.
A positive screening result that doesn't lead to a care plan, a referral, or a follow-up conversation with the patient's family is a missed opportunity at best, and a liability at worst. CMS's own cognitive assessment and care planning framework (CPT 99483) exists precisely because detection without action is clinically insufficient.
The shift in thinking that Neurotrack is leading, is from cognitive screening to cognitive care enablement. That means:
◆ Detection at scale: standardized, clinically-validated assessment embedded into routine care
◆ Documentation with specificity: objective scores, clinical interpretations, and RADV-ready records that satisfy V28 requirements
◆ Care pathway activation: referral recommendations, care plan generation, and connection to disease management resources
◆ Longitudinal monitoring: follow-up assessments that track change over time and trigger escalation when needed
◆ Family and caregiver integration: tools that extend the clinical relationship into the home
This is not a feature list. It is a care philosophy. And it's one that aligns precisely with where CMS policy and the growing population of cognitively vulnerable seniors is pushing the healthcare system.
The Window Is Open. The Question Is Whether You'll Walk Through It.
The underdetection crisis in cognitive care is not inevitable. It is a product of misaligned incentives, inadequate tools, and workflows that were never designed to catch a condition that hides in plain sight.
CMS V28 has changed the incentive structure. Digital screening platforms have changed the workflow. The clinical case for early detection, access to treatment, care planning, family preparation, and reduction of downstream costs has never been stronger.
What remains is the will to act: to make cognitive screening routine, systematic, and connected to the care pathways that give detection its meaning for earlier, more impactful care outcomes.
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80% of seniors 65–80 aren't screened today. That's the gap. That's the opportunity. |
The organizations that are building cognitive screening into their Annual Wellness Visits, aligning their documentation practices with V28 requirements, and investing in platforms that enable the full care journey are not just doing the right thing for patients. They are building the infrastructure that will define quality, compliance, and competitive positioning in Medicare Advantage for the next decade, just when our 65+ population will need it the most.
The underdetection crisis is real. It's also solvable. The tools exist. The incentives are aligned. The window is open.
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Ready to close the gap? Neurotrack's Cognitive Care Enablement Platform gives health systems and Medicare Advantage plans the tools to screen every eligible patient, document with the specificity V28 demands, and activate the care pathways that follow. Let's talk. neurotrack.com | Schedule a Demo |