What is prospective risk review in risk adjustment?

Prospective risk review is a pre-encounter process in which clinical analysts screen patient charts before scheduled appointments to identify potential HCC-relevant chronic conditions not currently documented. This allows providers to address and document these conditions during the encounter — capturing risk at the point of care rather than requiring costly retrospective corrections or missed RAF opportunities.

What clinical indicators are reviewed in prospective risk analysis?

Prospective risk analysis reviews prior encounter histories, medication lists, lab results, imaging findings, and treatment patterns for clinical indicators suggesting undocumented chronic conditions — such as elevated HbA1c suggesting undiagnosed diabetes, diuretic use suggesting heart failure, or lung function tests suggesting COPD. These indicators guide provider prep sheets and documentation guidance for the upcoming visit.

What are provider prep sheets in prospective risk review?

Provider prep sheets are structured, patient-specific summaries delivered to clinicians ahead of scheduled encounters. They highlight potential HCC gaps — conditions that may be present based on clinical indicators but are not currently documented — and include MEAT/TAMPER-aligned guidance to help providers assess and document these conditions accurately during the visit, improving both care quality and risk capture.

How does prospective review reduce the need for retrospective corrections?

By identifying and addressing HCC gaps before claims are submitted, prospective review eliminates the need for expensive and time-consuming retrospective chart reviews and corrected claim submissions. Conditions are captured with proper documentation during the encounter, resulting in more accurate RAF scores, cleaner initial claim submissions, and lower administrative burden for coding and compliance teams.

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Prospective Risk Review

Catch Risk Early — Before the Encounter

Our prospective review program screens charts before the visit, identifies clinical indicators of undocumented chronic conditions, and supplies provider-ready summaries so risk is captured during the encounter, not recovered after it.

Pre-Visit Screening Clinical Indicators HCC Gaps Provider Prep Sheets MEAT/TAMPER Submission Prep

Our Services

Full-Service Delivery

Pre-Visit Chart Screening

Reviewing prior charts, encounter history, and clinical indicators before scheduled visits.

Clinical Indicator Analysis

Identify symptoms, labs, imaging, and treatments suggesting undocumented chronic conditions.

HCC Gap Identification

Highlight conditions treated in prior years that may not be documented in the current year.

Provider Prep Sheets

Structured summaries delivered to providers ahead of encounters to guide documentation.

Documentation Guidance

MEAT/TAMPER-aligned templates and query support to improve encounter-level documentation.

Submission Preparation

Validate captured conditions and ready them for submission workflows.

How We Work

A Structured Workflow

Identify

Pull upcoming encounters and prior-year chronic condition profiles.

Screen

Review clinical indicators, labs, imaging, and history for HCC relevance.

Summarise

Produce provider-facing prep sheets with evidence and suspected conditions.

Deliver

Route summaries to providers ahead of appointments.

Validate

Post-visit, validate documented conditions meet MEAT/TAMPER.

Submit

Ready validated conditions for risk adjustment submission.