Risk Adjustment Operations

Every payment year starts empty. A chronic condition documented last year earns nothing this year unless a clinician sees the member again, evaluates it again, and documents it again. So you run two lists that behave differently: conditions coded in a prior year that have not appeared yet this year, and conditions never coded at all that the data hints at — a member filling a diabetes medication with no diabetes on this year's claims, a laboratory result a clinician would have acted on, a referral pattern that only makes sense if something is being treated. Then comes the part that is actually your job: deciding which suspects are worth pursuing. Each one spends something. A line on a gap list handed to a practice that already resents your gap lists. An outreach call to a member who did not ask for one. A chart request, or a home visit. And a bad suspect costs more than nothing, because you are telling a physician their patient may have a condition, and if it gets documented because you asked rather than because they found it, you have manufactured the exact record an auditor will read back to you. All of it runs against a calendar: the encounter has to happen, be documented, be coded, be submitted, and clear editing before the year's submission deadline.

You need records from practices that do not work for you. Some sites grant remote access to their system, some let an abstractor come on site, some fax, some mail a disc, some do not answer until someone calls again. You run it as a chase: sites, contacts, requests outstanding, records received, and the steady fraction that arrive wrong — the wrong member, the wrong date of service, a scan missing the header, a signed page where the signature carries no credential beside it. What arrives goes to coders, who read the encounter and decide which diagnoses that documentation actually supports for that date of service. Not what the suspect list said. Not what the problem list has been carrying forward for years. What a clinician evaluated or treated and signed. The work runs both directions: you add conditions the provider's claim never carried, and you delete conditions that were submitted and are not supported by the record you just pulled. The second half is the half that slips when the calendar tightens, and it is the half you will be asked about. Second-level review, coder disagreement over whether a single line supports a condition, and rework on records that came back illegible are all routine. Everything has to clear submission editing and land before the deadline.

You submitted the diagnoses; now you have to prove them. A sample of enrollees is drawn from the contract, and for each sampled member and each condition you have to produce the medical record that supports it: right member, right date of service, an acceptable provider type in an acceptable setting, a legible signature with a credential, and the condition documented clearly enough that a stranger reading it agrees with you. The encounters are from an earlier payment year, and the practices that held them may have closed, merged, changed systems, or have no memory of the visit. So most of the work is logistics under a clock — finding the best record you already hold for each condition, chasing what you do not hold, checking it against the criteria before you send it rather than after, and deciding what to do when the only record you can find is thin. Some conditions will not be supported. Someone has to decide whether to send a weak record, send nothing, or delete the code before the audit reaches it. The findings do not stay inside the sample either: an error rate can be extrapolated across the contract, which is what turns a coding disagreement into a balance-sheet event. Underneath all of it you run your own audits, because finding the unsupported condition before CMS does is the only version of this that ends well.