Most health plans leave money on the table. Not because they’re careless, but because their systems aren’t designed to catch every opportunity. A patient comes in for a routine visit, the provider addresses the immediate concern, and nobody thinks to document the patient’s ongoing chronic conditions. Six months later, during a retrospective review, someone finally notices: this diabetic patient with CKD hasn’t had those conditions coded all year.

That’s lost revenue you can never get back. Unless you know how to do retrospective risk adjustment right.

Why Retrospective Reviews Matter

Here’s the reality: providers are focused on patient care, not perfect documentation. They’re managing exam room flow, addressing acute issues, and trying to stay on schedule. Expecting them to remember every HCC-eligible condition during every visit is unrealistic.

That’s where retrospective risk adjustment comes in. It’s your chance to go back through the year’s charts and identify conditions that were documented but never coded. These aren’t phantom diagnoses or creative interpretations. These are real conditions, clearly present in the clinical notes, that simply got missed during the initial coding process.

The opportunity is bigger than most people realize. In a typical health plan population, 10-15% of legitimate HCCs go uncaptured during prospective coding. For a plan with 20,000 members, that can translate to $2-4 million in lost revenue each year.

The Two Sides of Retrospective Coding

There are two types of conditions you’re looking for, and both matter for different reasons.

First, there are “adds.” These are conditions clearly documented in the chart but never submitted to CMS. The provider wrote “patient’s COPD is well-controlled on current inhaler regimen,” but the claim only showed an acute respiratory infection. That COPD diagnosis? It’s sitting right there in the note, eligible for coding, but it never made it to your risk score.

Second, there are “deletes.” These are conditions you claimed but can’t actually support with documentation. The diagnosis was on the claim, but when you go back to review the chart, there’s no evidence the condition was active during that encounter. CMS is very clear about this: if you can’t support it, you need to delete it before an audit finds it.

Both matter. Adds represent revenue recovery. Deletes represent audit risk mitigation. A good retrospective program handles both.

The Challenges Most Organizations Face

Doing retrospective reviews manually is brutal. You’re asking coders to review hundreds or thousands of charts, looking for conditions that might or might not be documented, reading through lengthy progress notes and trying to apply HCC rules they memorized months ago.

The volume is overwhelming. Most plans don’t have enough internal resources to review 100% of charts, so they sample. But sampling means you’re definitely leaving money on the table. You’re just hoping the money you do find makes up for the money you don’t.

The accuracy problem is just as bad. Coders are human. They get tired, they miss things, and different coders interpret documentation differently. You might have one coder who aggressively codes based on minimal evidence and another who’s overly conservative. That inconsistency creates both revenue loss and audit risk.

And then there’s the time problem. By the time you’ve retrieved charts, distributed them to coders, completed reviews, handled queries, and gotten everything validated, you might be 8-10 weeks into a process that needs to be done before submission deadlines.

What Works Better

The most effective retrospective programs have three things in common.

First, they prioritize strategically. You can’t review every chart for every member, so focus on high-value opportunities. Target members with complex chronic conditions who had multiple encounters. Look at patients with historical HCC patterns who suddenly show gaps in their current year coding. Identify provider outliers who consistently under-document compared to their peers.

Second, they use technology to scale. Manual chart review will always be a bottleneck. Automated tools can pre-screen charts, flagging likely opportunities and surfacing relevant documentation sections. This doesn’t replace coder judgment, but it makes that judgment more efficient. Instead of spending 40 minutes per chart, your team spends 8-10 minutes on the charts that actually matter.

Third, they integrate feedback into the prospective process. The goal isn’t just to fix last year’s problems. It’s to prevent next year’s problems. When your retrospective reviews consistently find missed opportunities from certain providers or certain condition types, that’s telling you where your prospective process needs strengthening.

The Compliance Balance

Here’s what keeps compliance officers up at night: retrospective risk adjustment can find both revenue opportunities and audit liabilities. You want to maximize legitimate adds, but you also need to identify and fix unsupported codes before CMS does.

That means your retrospective program needs robust documentation standards. Every add should have clear supporting evidence. Every delete should be documented and tracked. And everything should create an audit trail showing you followed a consistent, defensible process.

Done right, retrospective risk adjustment isn’t just about recovering revenue. It’s about proving you have control over your risk adjustment process.