Prospective vs. Concurrent vs. Retrospective Risk Review: Which Is Best?

Compare the three core risk adjustment review strategies—timing, costs, accuracy, and compliance risk. Learn which approach works best for your health plan's goals and population.

The Three Risk Review Strategies: Direct Answer

There is no single "best" review strategy. Each has distinct advantages, limitations, and optimal use cases. Leading plans use all three in a carefully orchestrated sequence.

Prospective Review: Pre-Patient Encounter

What It Is

Prospective review identifies members with suspected but undocumented HCC conditions before or early in the service year and alerts providers to confirm or rule out conditions during upcoming visits.

Process

1. Identify members with suspected gaps using predictive algorithms (medication patterns, lab values, prior diagnoses, claims history).
2. Generate provider alerts with clinical rationale (why we think the member has this condition).
3. Request provider confirmation through electronic or paper alerts.
4. Retrieve and validate any new documentation.
5. Submit confirmed diagnoses to CMS as part of regular claims.

Advantages

• Highest ROI: Captures conditions in real time, avoiding retrospective efforts.
• Clinical benefit: Alerts help providers identify unrecognized conditions, improving patient care.
• Operational efficiency: Avoids late-year rush; documentation is fresh and complete.
• Provider engagement: Proactive approach builds positive provider relationships.
• Compliance-friendly: Early documentation captures have full support in medical records.

Limitations

• Provider alert fatigue: Too many alerts reduce response rates; must target carefully.
• Provider resistance: Some providers view alerts as inappropriate "coding fishing."
• Implementation complexity: Requires sophisticated predictive algorithms and workflow infrastructure.
• Response rate variability: High-performing providers respond 70-80%; low-performers respond <30%.

Concurrent Review: During Service Year

What It Is

Concurrent review validates diagnoses against clinical evidence during the service year (typically Q2-Q4) and requests corrections, clarifications, or new documentation for gaps.

Process

1. Monitor submitted claims and encounters in real time.
2. Identify diagnoses lacking clinical support or requiring validation.
3. Request medical records for validation review.
4. Conduct clinical review; request provider correction or clarification.
5. Track and resubmit corrected claims before year-end.

Advantages

• Mid-course correction: Catches and fixes errors before final submission.
• Improved accuracy: Detailed validation improves overall coding quality.
• Care coordination alignment: Concurrent validation supports case management efforts.
• Audit readiness: Early validation strengthens RADV defensibility.

Limitations

• Higher operational cost: Record retrieval and clinical review are labor-intensive.
• Time pressure: Limited time window for correction before year-end creates urgency.
• Provider burden: Requests for resubmission may encounter provider resistance.
• Limited new capture: Only validates existing submissions; doesn't identify new gaps like prospective review does.

Retrospective Review: After Service Year

What It Is

Retrospective review occurs after the service year ends and uses complete data visibility to identify missed conditions, validate all submitted diagnoses, and prepare supplemental submissions.

Process

1. Conduct comprehensive gap analysis using full-year data (claims, encounters, pharmacy, labs).
2. Retrieve and review medical records for identified gaps.
3. Validate against clinical evidence and CMS standards.
4. Prepare supplemental HCC submissions for final CMS reporting.
5. Assemble audit-ready documentation packages.

Advantages

• Complete data visibility: Full-year data enables comprehensive gap analysis.
• RADV audit support: Retrospective packages are audit-ready with full documentation trail.
• Supplemental capture: Can identify conditions missed in prospective and concurrent phases.
• Data quality focus: Opportunity to validate all diagnoses before final submission.

Limitations

• Limited submission window: CMS final submission deadlines allow only 60 days post-year for supplementals.
• High cost: Comprehensive record retrieval and clinical abstraction are expensive.
• Limited clinical relevance: Diagnoses identified after year-end don't improve member care.
• Provider fatigue: Late requests for documentation encounter resistance.
• Reduced capture: Only ~30-50% of retrospectively identified gaps can be captured due to time constraints.

Comparison Table: Accuracy, Cost, Timing, and Compliance Risk

Best Practices for Combining All Three Approaches

Integrated Timeline

1. January-September (Prospective): Deploy predictive alerts; engage providers proactively. Typical capture: 60-75% of gaps identified.
2. July-November (Concurrent): Validate submitted claims; request corrections. Typical capture: 40-60% of mid-year gaps.
3. December-February (Retrospective): Full gap analysis; supplemental submissions; RADV preparation. Typical capture: 20-40% of residual gaps.

Budget and Resource Allocation

For a 100,000-member plan with 6% underreporting rate:

• Prospective: $50K-150K (predictive models, alert infrastructure, provider outreach) — ROI 8-12x
• Concurrent: $200K-500K (record retrieval, clinical review) — ROI 4-8x
• Retrospective: $300K-800K (comprehensive abstraction, audit prep) — ROI 2-4x

Measurement Framework

Track for each approach:

• Gaps identified vs. gaps confirmed
• Cost per confirmed gap
• Revenue per confirmed gap
• Provider response rates
• Audit defensibility score

Frequently Asked Questions