Prospective Risk Adjustment is More Important Than Ever 


Download the eBook to learn why prospective review is critical in today’s increasingly competitive market:

  • Receive Accurate Reimbursements. Prospective capture of risk ensures accurate and timely reimbursements, whereas payments from retrospective review can be delayed by up to 18 months. Receiving revenue earlier rather than later helps organizations better manage their financial health.
  • Decrease Costs. Effective prospective risk capture decreases the need for in-home assessments, misaligned wellness activities, and retrospective risk adjustment that can be costly and resource-intensive. This is especially important for ACA commercial plans where margins are thin and the time allotted for retrospective review is less than in MA.
  • Close Care Gaps. Prospective risk identification helps physicians deliver the care that patients need, enabling organizations to improve population health and reduce medical expenditures over the long term. Effective prospective processes also facilitate better collaboration with provider partners for other critical initiatives such as closing HEDIS gaps.

View all eBooks in the Series

Ready To Go Deeper?

Visit our resources library to download the next eBook in the 360° Risk Adjustment series. The framework is divided into 8 core components:


  1. Overview and Blueprint to 360° Risk Adjustment
  2. Organizational Alignment
  3. Data & Performance Management
  4. Prospective Review
  5. Provider Engagement
  6. Data Acquisition
  7. Retrospective Review
  8. Compliance

Each piece is critical to overall success. Within each corresponding eBook, you'll find our strategic insights for transforming operations and detailed explanations on how to drive performance improvements.

Prospective Risk Adjustment

Receive Accurate Reimbursements, Decrease Costs, and Close Care Gaps with HF360 Prospective Risk Adjustment

Healthcare providers typically generate claims to be reimbursed for services provided. Information on medical claims, however, can be an incomplete account of patients’ health – providers are paid primarily based on procedure codes and not diagnosis codes. In order for an organization’s risk score to truly reflect the level of patient acuity, patient diagnoses must be accurately documented and coded.

Prospective risk adjustment refers to the effort of proactively identifying gaps in HCC capture and accurately documenting and coding for these risk conditions at the point of care. Many organizations – especially in the Medicare Advantage space – have experience deploying health risk assessments, conducting in-home assessments, and scheduling annual wellness visits to ensure accurate identification of risk conditions.

Download our HF360 Risk Analytics Data Sheet to learn more Health Fidelity's prospective risk adjustment solution.  

Download eBook Part 4:

Prospective Risk Adjustment

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