Prospective risk adjustment: Takeaways from our RISE panel

The risk adjustment landscape is entering a new era.

As RADV scrutiny intensifies and CMS moves toward encounter-based validation and clinically substantiated documentation, organizations are being forced to rethink how risk is captured, documented, and defended. 

What is still a largely retrospective workflow is becoming increasingly prospective, requiring risk-bearing organizations to move capture upstream and embed it into everyday clinical workflows.

That was the focus of a recent webinar hosted by Navina and RISE, featuring Gary Pilling II, President of VBC Health Advisors; Jonathan Meyers, CEO of Seldon Health Advisors; and Dr. Carlos Rodriguez, Vice President of Risk Adjustment and Clinical Performance at Aegis Medical Group.

Representing payer, provider, and operational perspectives, the panel explored what is driving this shift, what it means for audit readiness and financial performance, and how organizations are beginning to operationalize prospective risk adjustment in practice.

Here are the key themes that emerged from the discussion.

Why retrospective coding is losing ground

One of the first audience polls revealed that nearly 70% of attendees are operating in a hybrid model, combining retrospective and prospective approaches. 

These results reflect where much of the industry stands today: aware of the shift toward prospective risk adjustment, but still largely reliant on retrospective workflows. 

From a financial perspective, retrospective coding creates uncertainty. 

Risk adjustment performance depends not only on capturing diagnoses, but on being able to substantiate them. When conditions are identified months after the visit, organizations face greater exposure to audit risk, delayed revenue realization, and missed opportunities to accurately reflect patient complexity in real time.

As Jonathan Meyers explained:

"Just submitting the code up front and getting the revenue proactively could be at risk in the end. When they go to do RADV audits, the revenue is at risk because either you don't have the appropriate documentation for the code, or the doctor didn't do everything within the visit to substantiate it."

At the same time, CMS is continuing to raise the bar and the environment around those workflows is changing.

As the industry moves toward encounter-based validation, coding and documentation must increasingly stand on their own at the point of care. 

The ability to identify and correct issues after the fact is becoming more limited, placing greater importance on getting documentation right during the encounter itself.

But the implications extend beyond compliance and reimbursement.

When clinicians have a more complete picture of a patient's conditions during the visit, they can make more informed decisions, intervene earlier, and better manage disease progression. In that sense, prospective risk adjustment is not just a documentation strategy, it's a clinical strategy as well.

Moving upstream without overloading clinicians

Recognizing the need to move upstream is one thing. Making it work inside an already compressed clinical visit is another.

When attendees were asked about the biggest barrier to moving risk capture upstream, provider workflow burden was the top barrier. Most organizations understand the direction the industry is heading, but many are still grappling with how to improve documentation quality, strengthen audit readiness, and capture risk earlier without creating additional work for clinicians. 

Throughout the discussion, the panel returned to three capabilities that consistently separate successful prospective programs from unsuccessful ones: physician education, point-of-care intelligence, and real-time feedback loops. 

Lead with education

Any prospective model that simply adds more work is unlikely to last.

Dr. Rodriguez challenged the idea that prospective risk adjustment has to increase the physician’s load. Done well, he argued, it redistributes work and brings the right information into the visit at the right time.

Prospective workflows depend on physicians understanding not only what to document, but also why it matters. That includes documenting to the appropriate level of specificity, understanding how clinical evidence supports risk capture, and connecting documentation accuracy to both patient care and organizational performance.

Dr. Rodriguez described building a value-based care and documentation curriculum for physicians to close what he called the language gap between risk adjustment and clinical practice.

"Once they started understanding how value-based care works, the more they did it, the more it became a repetitive behavior."

Put intelligence inside the workflow

The panel contrasted prospective workflows with older approaches: faxed chart packets, nurses chasing documentation, and spreadsheets of suspected diagnoses pulled from multiple systems. 

Those methods often create confusion and force physicians to reconcile information after the fact.

A more effective model brings relevant clinical intelligence directly into the EHR at the point of care. Suspected conditions, supporting evidence, labs, medications, and referrals can be surfaced during the visit, while the physician retains clinical judgment over what to accept, hold, or reject.

As Gary Pilling II put it:

"There are tools such as Navina that integrate perfectly within the EHR, feeding them the information seamlessly."

The panel emphasized that this distinction matters. The goal is not to direct physicians or replace clinical judgment. It is to give them timely, evidence-backed suggestions so they can document more accurately in the moment.

Make audits real-time, not year-end

The same principle applies to audit readiness. 

A year-end chart review may identify documentation gaps, but by then, the opportunity to correct behavior has often passed.

The panel recommended moving audit activity closer to the encounter, where it can function less like a retrospective cleanup exercise and more like real-time coaching. When clinical reviewers identify documentation patterns soon after the visit, they can help physicians improve while the workflow is still fresh.

That shift turns audit readiness from a year-end scramble into an ongoing operating discipline.

What this means for plans and providers

While the operational challenges differ, the panelists agreed that health plans and provider organizations are ultimately moving toward the same goal: capturing and validating risk closer to the point of care.

For health plans, the shift is largely about visibility and defensibility. 

Traditional approaches rely heavily on claims data that may lag by months, retrospective chart reviews, and chart chase programs that are expensive to scale. 

As RADV scrutiny increases, many plans are looking for ways to bring risk capture closer to the clinical encounter, where documentation can be validated in real time rather than reconstructed later.

The panel emphasized that plans do not need to own the EHR to influence this process. 

Increasingly, organizations are finding compliant ways to surface relevant information within provider workflows, helping improve documentation quality, create greater consistency across the network, and provide more timely visibility into RAF performance.

For provider organizations, the shift is equally significant. 

As Medicare Advantage enrollment continues to grow and V28 raises the documentation bar, providers are under increasing pressure to ensure conditions are accurately captured and supported during the visit itself.

But the benefits extend beyond coding accuracy.

When clinicians have a more complete picture of a patient's history, conditions, medications, and potential care gaps before they walk into the exam room, they can spend less time searching for information and more time engaging with the patient. 

Better documentation becomes a byproduct of a better-informed clinical encounter.

As Dr. Rodriguez explained:

"We've seen happier physicians because they have more time to sit down with the patient instead of sitting on the computer."

Ultimately, the panel's message was that prospective risk adjustment is not just a documentation initiative. For both plans and providers, it represents a broader shift toward more timely information, better decision-making, and stronger alignment between clinical care and risk performance.

The takeaway

The panelists approached the discussion from different perspectives—payer, provider, and operations—but arrived at the same conclusion: the shift to prospective risk adjustment is already underway.

What is changing is not just where risk is captured, but how organizations think about documentation, audit readiness, clinical workflows, and performance management. 

Retrospective review will continue to play a role, but increasingly, success will depend on an organization's ability to capture and validate risk during the encounter itself.

For health plans, that means creating greater visibility into RAF performance and documentation quality across the network. 

For provider organizations, it means equipping clinicians with the information they need to document accurately without adding administrative burden.

The organizations making progress are not waiting for 2027 to force the issue. They are using today's regulatory and audit pressures as an opportunity to build more sustainable workflows, stronger documentation practices, and a more proactive approach to risk adjustment.

As prospective risk adjustment becomes the industry standard, the question is no longer whether organizations will make the shift, it is how prepared they will be when it arrives.

This article highlights a few key themes from the discussion. To watch the conversation in full, access the recording here.