Dr. Martinez called me at 8 AM, furious. “Your risk adjustment team keeps asking me to add diagnoses after my visits. I documented everything correctly. Why are you hassling me about codes I didn’t miss?”
She was right. We were failing at prospective risk adjustment coding so badly that we’d turned our providers into retrospective cleanup crews. That morning call changed how we approach the entire process.
The Timeline Disaster We Created
Here’s the insanity we’d accepted as normal: providers see patients, document encounters, submit claims. Weeks later, our coding team reviews notes and finds gaps. Then we chase providers for addendums, clarifications, and attestations about visits they barely remember. By the time we submit codes, the patient interaction is ancient history.
We were doing prospective risk adjustment retrospectively. Think about that stupidity for a second.
The real kick in the teeth? Providers actually WANT to document completely. Dr. Martinez spent extra time ensuring her notes were thorough. But she didn’t know that writing “kidney problems” instead of “chronic kidney disease stage 3” cost us $8,000. She didn’t realize that documenting “depression controlled with medication” needed the word “major” to capture the HCC.
I pulled data on our provider queries last month. We sent 1,847 requests for clarification on encounters from the previous quarter. That’s 1,847 times we interrupted patient care to fix old documentation. Each query took providers average 12 minutes to address. That’s 370 hours of provider time wasted because we couldn’t get the process right upfront.
The Pre-Visit Solution Nobody Wants to Hear
Everyone talks about point-of-care risk adjustment like it’s revolutionary. It’s not. It’s too late. By the time the provider is in the room with the patient, they’re focused on care, not codes. The revolution happens BEFORE the visit.
We started sending providers simple pre-visit prep sheets. Not 10-page reports. One sheet. “Mr. Johnson is scheduled tomorrow. Last year’s diagnoses included CHF and CKD Stage 3. Please assess and document current status.” That’s it.
The resistance was immediate. “Another administrative task!” But here’s what happened: providers started appreciating knowing what to look for. Dr. Martinez told me, “I would have asked Mr. Johnson about his kidney function anyway, but knowing it needed documentation helped me be more specific.”
Pre-visit prep takes our team 2 minutes per patient. The documentation improvement saves 20 minutes of retrospective cleanup. The math isn’t complicated, but somehow most organizations can’t figure it out.
The Real-Time Intervention
We killed the retrospective query process. Dead. Gone. If documentation needs clarification, it happens before the provider leaves the exam room, period.
Our embedded coders (really just nurses who understand HCCs) review notes while providers see their next patient. Takes 30 seconds. If something’s missing, they knock: “Hey, can you clarify the depression severity?” Provider adds six words to the note. Done. No queries three months later. No addendums about forgotten visits.
The doctors actually prefer this. Dr. Thompson told me last week, “I’d rather fix it while I remember the patient than get an email about it during my vacation.”
But here’s the critical part: we don’t interrupt for everything. Stable hypertension documented clearly? Move on. But when the note mentions “diabetes complications” without specificity, that’s worth 30 seconds of clarification that saves thousands in lost revenue.
The Provider Scoreboard That Actually Works
We tried provider scorecards before. They failed because they measured the wrong things. “Dr. Smith, your HCC capture rate is 67%” means nothing to someone who went to medical school to help patients, not optimize risk scores.
Our new scoreboard is different. It shows one metric: “Patients whose conditions were documented completely.” Not codes. Not HCCs. Just complete clinical documentation.
Dr. Martinez leads at 94%. Not because she learned coding rules, but because she gets the pre-visit prep and responds to real-time clarifications. She hasn’t changed how she practices medicine. We changed how we support her documentation.
The competitive aspect kicked in naturally. Nobody wants to be the provider whose patients’ conditions aren’t fully documented. When we framed it as clinical completeness rather than coding accuracy, physician engagement skyrocketed.
Your Wednesday Afternoon Test
Want to know if your prospective risk adjustment is actually prospective? Check Wednesday afternoon’s provider schedules for Thursday. Now check if those providers know which chronic conditions need documentation for tomorrow’s patients. They don’t? You’re doing retrospective cleanup, not prospective capture.
Count how many documentation queries you sent last month about encounters over 30 days old. Every single one represents prospective failure. You’re not capturing risk adjustment prospectively; you’re just hoping to fix it later.
Here’s the brutal truth: if providers need to addend notes after visits, your prospective program has already failed. If coders are reviewing yesterday’s encounters, you’re too late. If you’re querying about last month’s visits, you’re not doing prospective anything.
Real prospective risk adjustment happens before and during visits, not after. Support providers when they can act on it, not when it’s history. The 10 minutes you invest before visits saves hours of cleanup and captures millions in revenue that retrospective patches miss.
Dr. Martinez hasn’t called me angry in six months. She’s too busy leading our documentation completeness scores while practicing medicine the way she always has. That’s what prospective success actually looks like.
