When preparing for a patient visit, clinicians and their staff must often sift through claims, clinical notes, and historical conditions across multiple systems, often without a unified view or clear prioritization. This manual approach leads to missed recapture opportunities, inconsistent documentation, and unnecessary administrative burden—a challenge that one regional health system knows well.
A prominent nonprofit, academic health system with a large accountable care organization (ACO) risk adjustment operation has developed a reputation for its commitment to value-based care. The organization manages its own health plan while also partnering with several unaffiliated health plans.
Embedded within the organization’s division of population health is an actuarial informatics team, which oversees all value-based care contracts. The team’s mission is clear: deliver the right information at the right time to the right people, ensuring optimal patient outcomes and organizational success.
The challenge: Rudimentary risk capture led to suboptimal results
Despite its strengths, the client faced substantial challenges in its risk adjustment program. Around 2020, its payer partners highlighted that its risk capture rates were lagging behind market peers, especially those with established programs and formalized partnerships.
The health system’s initial strategy relied heavily on manually creating recapture lists and focusing on re-documenting previously identified conditions. This approach, while supporting certain compliance and documentation objectives, did little to drive improvements in its overall risk score accuracy or to consistently identify new, clinically supported, uncoded conditions. As the client described, “it's like treading water.”
Provider engagement posed another significant hurdle. Some clinicians did not see the value of risk adjustment in enhancing care delivery or patient outcomes, making it difficult to motivate them to participate actively in the program. In addition, about 30% of patient visits were scheduled as same-day or next-day appointments, leaving insufficient time to prepare comprehensive lists of suspected conditions before the visit.
Data quality and interoperability further complicated the process: the organization’s multiple electronic health record (EHR) systems and varying payer data formats created obstacles to efficiently extracting and synthesizing clinical information. As the client put it, “if you’ve seen one payer’s data, you’ve seen one payer’s data.”
The solution: Data-driven pre-visit preparation
Recognizing the need for a more proactive and effective approach, the client sought to move beyond manual recapture methods. The organization turned to Cotiviti to support a comprehensive pre-visit preparation strategy and enhance disease burden capture. The deployment of Cotiviti’s technology enabled the organization to surface potentially relevant, clinically supported suspected conditions for review for every patient in its attributed population, shifting the focus from simply recapturing historical diagnoses to actively identifying new, clinically supported, uncoded conditions.
Qualified clinical reviewers played a pivotal role in this transformation. Leveraging Cotiviti’s suspecting capabilities, reviewers evaluated potential conditions supported by available clinical evidence and routed relevant insights to clinicians at the point of care. This workflow supported more complete and accurate documentation while helping to reduce inappropriate coding. Leveraging machine learning and natural language processing, reviewers assessed whether available documentation supported further clinical evaluation, and any diagnoses were determined by the treating clinician during patient encounters.
To address the challenge of short-notice appointments, the client shifted to evaluating its full attributed population in advance. Beginning each October, the team conducts comprehensive prospective chart reviews of patients expected in the upcoming year, updating as new members are added to payer rosters. This proactive approach ensures that regardless of when a patient came in, clinicians had timely access to relevant risk and quality information. The health system also leveraged payer rosters to maximize patient engagement, with dedicated outreach teams contacting patients without annual wellness visits to encourage scheduling and attendance.
Expanding beyond primary care, the organization strategically involved specialists, including those in cardiology, endocrinology, oncology, pulmonology, and transplant medicine, in the process. The organization identified conditions commonly missed by primary care providers and collaborated with Cotiviti to stratify and route those identified clinical documentation gaps or potential conditions to the appropriate specialty teams.
Achieving measurable improvement and driving value
The partnership with Cotiviti has delivered significant, measurable results for the client. By 2025, payers recognized the client as a leading performer in the region for risk capture. On average, based on internal analyses from 2023–2025, 36% of risk adjustment factor (RAF) points included on claims originated from conditions not historically coded but subsequently identified as clinically supported—a clear indicator of success in identifying new disease burden opportunities within this program context. In addition, 27% of the patient roster was identified as having at least one potential new or recapture condition for clinical review, and 10% of patients had at least one such condition documented and coded, where clinically appropriate.
The accuracy and acceptance of identified potential conditions also improved. Over the same period, 36% of suspects surfaced by Pre-Visit Prep were considered appropriate for clinician review by a clinical reviewer, and reviewers identified 105 different hierarchical condition category (HCC) code types, representing 91% of the total HCCs available in Model V28. These achievements underscore the comprehensive reach of the program and its effectiveness in supporting the identification and documentation of both new and existing conditions across the patient panel.
Beyond risk capture, the program has generated tangible benefits for the health system’s payer partners. The improved prospective capture of conditions at the point of care contributed to a reduction in retrospective chart review activities, streamlining certain compliance and audit processes and saving payers both time and resources. Clinical reviewers and clinicians now operate within a robust workflow that prioritizes accuracy and appropriateness, supporting accurate and complete clinical documentation and reducing the risk of unsupported diagnoses or missed documentation.
The organization’s chase list and risk ranking processes further support closing both risk and quality gaps. By prioritizing outreach to patients with the most significant unaddressed clinical and documentation needs, the health system helps increase the likelihood that each patient encounter is able to address high-value, clinically appropriate interventions. Integration of EHR alerts at the point of care helps clinicians stay informed about open care gaps and potential conditions for evaluation, supporting informed decision-making and contributing to improved care coordination and organizational performance.
Looking forward: Further opportunities for improvement
For the client, scaling the engagement of specialists remains a strategic priority. While six specialties are currently participating in Pre-Visit Prep, the health system aims to expand this model to additional clinical areas, helping to ensure relevant clinical and documentation needs are appropriately identified and addressed. Ongoing education and incentive strategies will be essential to maintain and strengthen provider engagement.
Looking ahead, the client also recognizes opportunities to further align its risk adjustment and quality gap closure strategies with broader organizational goals. For example, closing specific quality gaps, such as breast cancer screenings, can help the organization achieve elevated performance tiers in value-based contracts. Enhancing provider awareness of these connections, as well as continuing to refine risk ranking methodologies, will position the health system for sustained success in an increasingly complex healthcare environment.
A value-based care success story
This client’s strategic partnership with Cotiviti has significantly evolved its approach to risk adjustment, moving from manual, retrospective processes to a proactive, technology-driven model. Through the implementation of Pre-Visit Prep, clinical reviewer workflows, and targeted provider engagement strategies, the organization has taken significant steps to improve risk capture and operational workflows, while supporting value for patients and payer partners.
As the health system continues to address data quality and interoperability challenges, and scales its specialist engagement, it stands poised to build on its achievements and set new standards for value-based care in the region.
Learn how our Pre‑Visit Prep solution leverages AI and NLP in combination with clinical review validation to help prepare clinicians for patient encounters, bridging the gap between advanced analytics and real‑world clinical workflows.
