CMS’s expanding RADV audit activity is changing the economics of risk adjustment. The question is no longer whether organizations can optimize retrospective chart chase. The question is whether their operating model can withstand continuous audit scrutiny at enterprise scale. Retrospective workflows that were designed to validate a handful of codes are increasingly difficult to sustain in today’s regulatory and financial environment.
Retrospective chart chase was designed to validate a handful of codes, not to withstand continuous audit scrutiny at enterprise scale. Reconstructing documentation months or years after the encounter is slow, costly, and increasingly exposes health plans to financial and operational risk.
That is why payer leaders from Community Health Choice, Community Health Plan of Washington, and Clear Spring Healthcare are shifting risk adjustment upstream, capturing accurate clinical information at the point of care while it still counts. Their experience points to a proactive, clinical-first model that lowers audit exposure, reduces operational costs, and strengthens provider relationships.
This executive summary distills their discussion into practical insights, lessons learned, and real-world strategies for organizations evaluating the transition to a clinical-first approach to risk adjustment.
What You’ll Learn
- Why retrospective workflows are becoming increasingly difficult to sustain under today’s audit environment
- How leading organizations are capturing documentation at the point of care
- How CCDs, ADT feeds, and real-time clinical data support earlier intervention
- Why provider engagement is foundational to a clinical-first approach
- Practical insights from payer and clinical leaders who are implementing clinical-first risk adjustment strategies
Download the executive summary to learn how payer leaders are modernizing risk adjustment, reducing audit exposure, and building the clinical data foundation for the next generation of healthcare operations.