One Chart, Two Wins: Unifying Risk Adjustment and HEDIS Chart Review

Health plans routinely pay to review the same chart twice: once for retrospective risk adjustment and again for HEDIS/Stars hybrid medical record review, with separate teams, separate vendors, separate retrieval windows, and separate budgets. Pressure is building on both sides at once. V28 is fully phased in, more than 2,000 payable ICD-10 codes are gone, and average MA risk scores are down roughly 3%. On the quality side, CMS is actively trimming the Stars measure set and NCQA keeps shifting measures into ECDS, so denominators and exclusion logic (statin measures among the most recent examples) are moving year over year. As quality bonus payments and rebate dollars carry more of the margin, risk and quality can no longer operate as parallel priorities. They are the same P&L, working from the same data.

That's the opportunity. The chart is a shared asset and unifying it doesn't require a reorg or a new intervention, just a re-sequencing of two programs that are already funded and in flight. In this session, we'll explore how one chart retrieval and review pass can serve both HCC coding and HEDIS/Star Ratings, producing three distinct value streams from a single record set: denominator relief through exclusion capture, true numerator gap closure through supplemental data loaded before the hybrid sample is drawn, and a smaller, higher-yield hybrid sample as the downstream dividend. Attendees will walk away with evidence-based strategies to cut retrieval spend, ease provider abrasion, accelerate gap closure, and get two results from one set of data using infrastructure they already own.
 

Key Takeaways: 

1. Understand the anatomy of the duplicate review problem, including the structural and timing challenges that cause inefficiencies in risk adjustment and quality 
2. Learn how one retrieval and review pass can serve both retrospective risk adjustment and HEDIS/Star Ratings cycles: one data set, two programs, no reorg required 
3. Explore how true gap closure is achieved through exclusion capture, dual abstraction, disposition tracking, and audit trails, and how to keep exclusion logic current as CMS and NCQA continue revising the measure set 
4. See how coding scale and dual-credentialed expertise make integration possible, with one bench fluent in both HCC risk adjustment and HEDIS abstraction, so plans review the chart once instead of paying twice 
5. Discover how advanced technologies act as detection engines and support the transition to a post-hybrid environment, preparing teams for full population quality reporting