For years, many organizations have approached risk adjustment in healthcare as work that happens after the patient encounter. Documentation is reviewed and coding teams reconcile charts to ensure diagnoses accurately reflect the care that was delivered. While that process remains important, it is becoming increasingly difficult to meet the goals of value-based care when risk adjustment documentation and coding remain largely retrospective.
Leading organizations are beginning to view risk adjustment as a clinical program woven into care delivery rather than a downstream administrative function. This shift enables clinicians to capture patient complexity more accurately while giving payers and providers a clearer understanding of the populations they serve. The result is a stronger foundation for financial sustainability under value-based payment models.
As Virtix Health President Carey Ketelsen puts it, risk adjustment only truly works when it is embedded in clinical care rather than treated as a separate administrative process. It calls for a shared operating model in which payers, providers, coders, and care teams work from the same data, speak the same clinical language, and align around a common goal: accurately capturing each patient's health while the information is still clinically relevant.
What Is Risk Adjustment in Healthcare
Healthcare risk adjustment has long been associated with coding accuracy and reimbursement. Those outcomes remain important, but they represent only part of its value. When a patient's Risk Adjustment Factor (RAF) score doesn't reflect their true clinical complexity, organizations aren't competing on a level playing field. According to Ketelsen, organizations with that mismatch are "either leaving revenue on the table or taking on risk they haven't been paid to manage" and neither is sustainable. Financial performance, quality reporting, and care decisions all begin with an incomplete picture of the patient.
That disconnect often stems from misalignment across clinical, technology, and operational workflows. When the people responsible for care, documentation, and reimbursement aren't working from the same picture of the patient, chronic conditions are more likely to be missed or under documented. Across the millions of lives Virtix Health supports, with more than 13,000 dedicated resources focused on this work, clinical complexity is consistently undercoded, not because providers don't care, but because the systems and workflows around them aren't designed to catch it. The result is an organization that sees only part of the story, making it harder to allocate resources appropriately and accurately reflect the cost of caring for medically complex populations.
As value-based care expands, closing those gaps becomes increasingly important. Ketelsen argues that documentation is an extension of patient care, not simply a billing task. A shared understanding of the patient's health allows documentation to reflect clinical reality more accurately, supporting better-informed care while ensuring reimbursement aligns with the true complexity of the patient.
Moving Healthcare Risk Adjustment Upstream
For many organizations, risk adjustment coding still begins after the patient encounter, when coding teams review documentation and reconcile diagnoses retrospectively. While retrospective review remains an important safeguard, Ketelsen believes that it should no longer carry the program on its own.
Leading organizations are instead building programs that combine prospective, concurrent, and retrospective approaches into a single clinical workflow. Before a patient arrives, clinicians receive relevant patient-specific insights that help focus the encounter. During or immediately after the visit, documentation can be clarified while clinical details are still fresh. Retrospective review then serves as a final layer of validation rather than the primary mechanism for identifying missed conditions.
Together, these approaches reinforce one another. Prospective insights prepare clinicians for the visit, concurrent documentation improves accuracy at the point of care, and retrospective review captures the remaining opportunities without becoming the program's primary engine. Importantly, this approach looks both ways: ensuring that valid conditions are captured and supported by documentation, while also removing diagnoses that are not adequately supported. The result is a more complete, and ultimately more defensible, picture of patient complexity.
Risk Adjustment Healthcare Technology Should Fit the Way Clinicians Work
As organizations move risk adjustment closer to the point of care, technology plays an increasingly important role. But according to Ketelsen, success depends less on sophisticated algorithms than on whether those solutions genuinely make clinicians' jobs easier.
Physicians already balance patient conversations, clinical decision-making, documentation requirements, and quality measures within every encounter. Technology creates value only when it simplifies that work, rather than adding another layer of administration.
That means delivering concise, patient-specific guidance supported by relevant clinical evidence within the clinician's existing workflow. When meaningful insights arrive before or during the encounter, physicians can confirm diagnoses, document disease severity, and address care gaps while clinical decisions are still being made.
By contrast, long lists of speculative documentation opportunities or disconnected applications that require clinicians to navigate multiple systems often create friction instead of improving documentation. Ketelsen describes clinicians as wanting “signal, not noise,” information that is accurate, encounter-relevant, and clearly prioritized. The most effective solutions work quietly in the background, surfacing AI-enabled, confidence-scored, clinically grounded recommendations with the supporting evidence already in place. Physicians get the information they need at the moment they can use it, without another system to navigate or another task to complete.
Equally important is deep integration into the electronic health record (EHR) and existing clinical workflows. Technology that feels bolted on or requires toggling between multiple systems introduces burden; technology that is embedded into day-to-day workflows drives adoption.
Making Better Habits Stick in Risk Adjustment Documentation and Coding
Creating lasting change requires more than new technology. It starts with cultivating feedback loops that make accurate documentation a natural extension of everyday clinical practice.
Traditional programs often rely on annual training sessions or one-time participation incentives. While those efforts may encourage short-term engagement, they rarely change how clinicians document care from one patient encounter to the next. Activity increases, but sustainable behavior changes do not.
Organizations are seeing stronger results by giving physicians timely visibility into documentation performance, gap closure, and risk capture. Transparent, near real-time feedback helps clinicians understand how their documentation affects not only reimbursement but also the accuracy of the patient record and the organization's ability to manage complex populations. As Ketelsen describes it, that shift shows up when a primary care physician looks at their panel and says, "My patients are being managed better. My documentation reflects their true complexity, and I'm receiving the resources to take care of them appropriately." That's the moment documentation stops feeling like an administrative requirement and starts feeling like an extension of patient care.
The same principle applies across the organization. Quality initiatives, care management, and risk adjustment coding often operate independently, each with its own priorities and reporting structure. Clinicians, however, experience them as part of a single workflow. Aligning those efforts helps organizations move in the same direction, reducing duplication and reinforcing shared goals across clinical workflows. Organizations that tie meaningful shared savings to performance, and integrate quality, risk, and care management from a single playbook are the ones that see sustained improvement.
Building Patient-Centered Risk Adjustment Coding Programs
As regulatory expectations continue to evolve, many organizations are asking what makes a risk adjustment program truly defensible. Ketelsen offers a different perspective: defensibility begins with patient care, not audit preparation.
Every diagnosis should be supported by clear, clinical evidence and reflect a condition that is actively monitored, evaluated, assessed, or treated. That defensibility holds up under scrutiny, whether the review comes from an internal audit or a formal RADV review from CMS. When documentation accurately represents the care patients receive, stronger compliance and more reliable reporting naturally follow.
That approach extends beyond documentation itself. Prospective engagement prepares clinicians before the visit. Concurrent documentation support helps capture clinical complexity while decisions are being made. Technology that provides confidence-scored, audit-ready evidence strengthens the integrity of every diagnosis. Together, these capabilities create programs that are resilient as payment models and regulatory expectations continue to evolve.
Defensibility also depends on better data sharing between payers and providers. Payers hold rich claims, utilization, and population-level data, while providers hold the clinical context needed to interpret that data. When these datasets come together in shared workflows and common solutions, both sides work from the same, more accurate picture of the patient.
Risk adjustment has evolved beyond a coding exercise into a shared clinical program. As payers and providers share data and work from the same picture of the patient, risk adjustment shifts from an adversarial process to a collaborative partnership that better supports patients and value-based care.
