Transforming HCC Risk Adjustment: From Q4 Scramble to Year-Round Success

If you work in value-based care, you know the feeling. It’s mid-October, and the data shows your ACO or MA plan is trailing behind its RAF (Risk Adjustment Factor) projections for the year. An email goes out to the clinical team: "We need a retrospective chart review immediately."

Suddenly, coders scramble to query physicians about visits that happened eight months ago. Physicians feel the strain of the "administrative burden" of reopening closed charts. Compliance officers grow anxious, knowing that aggressive end-of-year "sweeps" are a primary trigger for OIG audits.

This "Q4 scramble" is a symptom of a broken workflow. In 2026, with the blended CMS v24/v28 models and tighter audit scrutiny, relying on retrospective cleanup is no longer a viable strategy.

To protect your shared savings and reduce provider burnout, you must treat risk adjustment as a continuous clinical discipline, not a seasonal finance project. Here’s how to build a year-round HCC workflow that moves you from "chasing codes" to accurately capturing patient acuity in real time.

Why the “Retrospective Sweep” Model Is Broken

For years, many organizations operated on a cycle of "document now, fix later." They let clinical documentation happen naturally throughout the year, then hired vendors or tasked internal teams to comb through charts in Q4 to find missed HCCs.

This approach creates three major operational risks:

• Provider Abrasion: Asking a physician to verify a diagnosis from a visit that occurred in February is the fastest way to lose their engagement. They likely do not recall the specifics, and the disruption erodes trust between the coding team and the clinical frontline.

  
  

• Compliance Exposure: Retrospective reviews that only add codes—without deleting unsupported ones—are a red flag for regulators. When risk adjustment is purely a backend revenue cycle function, it looks less like care coordination and more like "upcoding."

  
  

• Financial Blind Spots: If you wait until Q4 to capture the bulk of your risk data, your CFO is flying blind for nine months of the year. You cannot accurately project benchmarks or manage P&L when your RAF score fluctuates wildly in the final quarter.

  
  

The 4-Quarter Approach to Risk Adjustment

A successful year-round HCC workflow smooths out the peaks and valleys of documentation. Instead of a year-end spike in activity, you distribute the work across four distinct operational phases.

Q1: Analysis & Education (The "Look Back & Look Forward")

While the finance team closes out the previous performance year, the clinical operations team should use Q1 to analyze the "drop-off" report. Which chronic conditions were captured in the prior year but haven't been addressed yet this year?

This is also the time for education. With the transition to CMS-HCC Model v28, many codes that were previously high-value (like certain mild depression or vascular diagnoses) may no longer carry weight, while others have gained importance. Use Q1 to update your providers on these specific changes so they don't waste time documenting for an outdated model.

Q2: Pre-Visit Planning & Point-of-Care

By spring, the focus shifts entirely to the Annual Wellness Visit (AWV). The goal here is prospective risk adjustment. Instead of asking a doctor to fix a note after the fact, we ensure the problem list is accurate before the patient walks into the exam room.

This involves scrubbing the schedule to ensure patients with historically high disease burdens are actually coming in. If a patient with CHF and Diabetes hasn't been seen by May, they are a priority for scheduling.

Q3: Concurrent Coding

In the summer and early autumn, the workflow moves to "concurrent" review—monitoring documentation within 24 to 48 hours of the encounter.

If a note is deficient (e.g., listing "Diabetes" without specifying complications or current status), the query should happen immediately. The clinical details are fresh in the provider's mind, making the clarification easy to answer and clinically relevant.

Q4: The Final Polish (Not the Panic)

If you have executed Q1–Q3 correctly, Q4 is not a scramble; it is a targeted cleanup. You are no longer reviewing every chart. You are only looking at the specific subset of patients who have suspected conditions that remain unaddressed. This reduces the volume of queries by 80–90%, saving your staff from burnout during the holidays.

Moving From Retrospective to Prospective with AI

The manual manpower required to run a prospective workflow used to be prohibitive. You couldn't pay enough nurses to pre-review every chart for every patient, every day. This is where AI changes the economics of risk adjustment.

Tools like ZynGap automate the pre-visit review. By analyzing the patient’s historical data, labs, and specialists' notes, AI can surface "suspect" conditions directly within the physician's workflow during the visit.

This shifts the dynamic from "correction" to "support." The AI isn't telling the doctor they made a mistake; it is reminding them: "This patient has a history of CKD Stage 3, but it hasn't been evaluated this year. Please assess."

Furthermore, predictive tools help with the scheduling component. As we discussed in our article on rising-risk patients, you can use ZynPredict to identify which patients are likely to have undocumented progression in their conditions. This allows you to prioritize outreach to the people who actually need clinical attention, rather than just calling down an alphabetical list.

Creating a Culture of Clinical Accuracy

Ultimately, risk adjustment is not about revenue; it is about telling the truth about a patient's health status.

To build a sustainable workflow, leadership must emphasize MEAT criteria (Monitor, Evaluate, Assess, Treat) not as a billing requirement, but as a standard of good care. If a condition is on the list, it is being managed. If it isn't being managed, it shouldn't be on the active list.

When you frame the conversation around clinical accuracy, physicians listen. When you frame it around "closing gaps for the ACO," they tune out.

Conclusion

The era of the "magic eraser" in Q4 is ending. As value-based care contracts become more sophisticated and audit risks rise, the only safe path forward is a steady, automated, and prospective approach to documentation.

A year-round HCC workflow protects your revenue, keeps your physicians focused on care, and ensures that your data actually reflects the complexity of the patients you serve.

Schedule a Demo