A health plan may retrieve a member’s medical record for risk adjustment in the fall, only to request the same chart again for Healthcare Effectiveness Data and Information Set (HEDIS) quality review a few months later. Both teams need reliable clinical evidence, but they often collect and review medical records separately, adding costs and creating more work for providers.
This raises a practical question: Could one chart retrieval support both risk adjustment and quality programs without compromising the standards of either review? For many plans, much of the information quality teams need may already be passing through the risk adjustment coding workflow. Making better use of those records could reduce duplicate work and help plans capture valuable clinical evidence earlier. The key is coordinating when and how the medical record reviews take place, while keeping each program’s requirements intact. With this fall’s retrieval season under way, there is still time to test the approach before the next HEDIS hybrid sample is drawn.
Why Do Risk Adjustment and Quality Teams Review the Same Chart Twice
Risk adjustment and quality teams have developed their own calendars, vendors and budgets for good reasons. They serve different reporting requirements and face different deadlines. But these arrangements can produce an expensive pattern: a provider receives two requests for the same chart, two reviewers examine it independently, and their findings land in systems that rarely connect.
Megan Piotrowski, Senior Director of Solution Architecture at Virtix Health, describes the underlying challenge as one of sequencing and data movement. Plans can start by mapping where the same record is retrieved more than once and determining whether an earlier review can supply evidence for a later one.
Consider a member whose chart is retrieved for hierarchical condition category (HCC) coding. That same chart may contain a blood pressure reading or evidence of advanced illness that becomes important during HEDIS review. If the risk adjustment and quality workflows don’t share information about records already obtained, the quality team may request a chart the plan already has.
Why Are Duplicate Medical Record Review Requests Harder to Justify Now
Every repeat retrieval carries direct expense, from provider outreach to chart transmission and medical record review. It also asks clinical practices to respond to requests they may feel they have already fulfilled. For plans managing constrained budgets, that burden deserves closer attention.
Pressure is rising on both the risk adjustment and quality sides. The V28 phase-in and CMS encounter linkage requirements make documentation integrity and the value of each chart review more important. Meanwhile, quality teams are working to improve performance under demanding measurement and reporting schedules. More chart activity alone does not guarantee a better result. As Piotrowski puts it, “Every dollar you spend opening a chart has to do two jobs.”
What Do the V28 and RADV Changes Mean for Chart Review
The numbers behind that pressure are specific. Piotrowski notes that V28 has completed its three-year phase-in, and that CMS projects model revision and normalization together will pull average Medicare Advantage risk scores down about 3%, with more than 2,000 ICD-10 codes no longer payable in the model. She adds that, for 2027 risk scores, chart review diagnoses that are not linked to a submitted encounter no longer count, that 2027 payment is built on 2026 dates of service, and that RADV audits are moving to every eligible MA contract every year. On the quality side, measurement year 2026 HEDIS data collected this winter and spring flows into 2028 Star Ratings.
How Missed Cross-Checks Create Compliance Risk
When risk and quality teams don’t compare findings, they can miss useful evidence. A diagnosis documented for risk adjustment might also support a quality exclusion. Conversely, a quality reviewer may notice a condition that was overlooked or inadequately supported during HCC coding. When the two reviews produce isolated audit trails, the plan loses a useful chance to examine discrepancies before they become compliance problems.
How Quality Data Supports Suspecting and Prospective Programs
The cross-check also reaches beyond retro coding. Lab values and vitals captured for quality, such as an eGFR pulled for a kidney health measure, will not support an HCC on their own, but they can support CKD staging, which remains payable under V28. That makes the quality pass a new source of evidence for suspecting and prospective programs as well.
How Can One Chart Support Risk Adjustment and Quality Programs
A sensible first step is to add quality evidence capture to charts already retrieved for risk adjustment. During the risk review cycle, plans can identify HEDIS exclusions and numerator evidence that may otherwise be discovered much later. This might include documentation of hospice or palliative care, dialysis, frailty or advanced illness, as well as eligible clinical results such as blood pressure readings, hemoglobin A1c values or retinal eye exams.
“One chart fully read can feed both risk and quality supplemental data at once,” Piotrowski explains.
Why Does Timing Matter Before the HEDIS Hybrid Sample
The timing can matter more than one might think. Finding an applicable exclusion before a HEDIS hybrid sample is drawn can improve the accuracy of the eligible population and reduce replacement-chart requests. Capturing qualifying numerator evidence early can also support supplemental data used to close gaps beyond the eventual sample, subject to the measure’s requirements and data validation.
Advanced Illness: One Finding, Two Outputs
Advanced illness shows how the same finding does double duty. Advanced illness reaches back into the prior year, so a 2025 chart documenting dementia or heart failure, paired with frailty evidence from the measurement year, can remove a member from the blood pressure control, glycemic status and eye exam measures at once. Dementia and heart failure are also payable V28 HCC categories, so the coder is not doing extra reading. They are producing a second output from a finding they have already made.
How Do Plans Keep Risk Adjustment Coding and HEDIS Review Distinct
Operational coordination must preserve clinical accountability. HCC diagnoses still require appropriately qualified risk adjustment coders following applicable federal standards. HEDIS evidence still needs qualified abstractors working under National Committee for Quality Assurance requirements. Plans can share retrieval, intake and chart routing while keeping separate review decisions, training and audit protocols.
Nor does this require a bench of reviewers who hold both skill sets, which Piotrowski calls far too rare to build a program around. What it needs is enough credentialed depth on each side, working the same chart in sequence.
Automation Needs Traceable Human Decisions
Keeping review decisions separate matters even when automation supports the workflow. Technology may flag passages for a reviewer, but the supporting evidence must remain traceable to the source record and the appropriate human determination. A common chart pipeline should strengthen that traceability rather than obscure who made each decision.
How Does an Evidence-Linked Audit Trail Support HCC Coding and RADV
For risk adjustment, this evidence-linked audit trail can strengthen support for a Risk Adjustment Data Validation (RADV) audit by tracing each submitted diagnosis to its supporting passage, date, and credentialed reviewer’s decision.
Start With a Second Pass and Measure What Changes
Plans do not need to redesign both programs at once. A limited pilot can leave the established HCC workflow intact, then send selected charts through a separate quality pass. Reviewing the chart for quality after HCC coding lets plans test whether earlier evidence capture reduces later work without disrupting coding throughput.
Size the Overlap Between Risk and HEDIS Populations
The first task is to compare the population targeted for risk adjustment retrieval with the members and measures likely to require HEDIS medical record review. Administrative data and previous chart-request lists can reveal overlap, but the percentage will vary by plan. Use that plan-specific overlap as the baseline for the business case, rather than relying on generic saving estimates.
The structure of the population suggests the overlap is large. Piotrowski cites that roughly 60% of Medicare beneficiaries carry a hypertension diagnosis, about 25% carry diabetes, and two-thirds have two or more chronic conditions. Those are the denominators for HEDIS measures such as blood pressure control and glycemic status, and the same members a risk sweep targets. The open question is how large the overlap is for a given plan.
Which Metrics Show the Pilot Is Working
From there, leaders can track how many charts the plan avoided retrieving a second time, exclusions identified before sampling and gaps closed through approved supplemental data. They should also examine provider repeat requests and documentation discrepancies identified across the two reviews. On the risk side, encounter linkage deserves particular attention because diagnoses submitted through chart review must meet applicable linkage requirements.
Piotrowski also points to a practical safeguard for teams worried about throughput: complete HCC coding first and have the quality team assess the same record afterward. This sequence lets plans keep the established risk process in place while measuring the additional findings and value from the quality review.
What Needs Approval Before a Pilot Starts
Two items gate a pilot: providing criteria files and getting supplemental data approved by the plan’s HEDIS auditor. Both can proceed in parallel while the risk sweep is still under way, so the work can begin before the sweep is complete.
Can a Clinical Data Pipeline Improve HEDIS Review Beyond One Season
The longer-term benefit extends beyond a single HEDIS season. When records are available earlier, quality teams can see which charts they already have before hybrid sampling begins. They can also decide whether a fresh request is necessary. A new hospital discharge, for example, may require additional documentation, while a previously reviewed encounter may already contain everything needed.
A more coordinated approach also prepares plans for growing reliance on encounter-linked information and digital quality reporting. As Piotrowski puts it, the goal is to turn fragmented record workflows into “a true clinical data pipeline.” In that model, evidence is captured once, tied to its source and sent to the programs authorized to use it.
Plans will still need to validate records carefully. Access to electronic records varies across provider networks, and the same data element may have different relevance under different measures. Starting with existing retrievals allows plans to improve their processes without assuming that every connection or automation capability is already in place.
Start With the Charts You Already Have
Plans have a concrete opportunity to reduce repeated work by checking what their risk and quality teams are already collecting. The most useful first move is an overlap assessment followed by a limited, measurable second-pass review. Together, these steps can show how much quality evidence is available earlier, how many repeat requests are avoidable and where documentation needs closer attention.
One medical record can support more than one program. Plans can capture more of its value by making its findings available to both risk adjustment and quality reviews, while keeping each program’s standards and decisions distinct.
Plans that want to size their own opportunity can share administrative data and prior chase lists with Virtix Health to model the overlap between the risk universe and the HEDIS-eligible population, including the share of chart review diagnoses that are already encounter-linked.
To explore a first-stage second pass, watch the on-demand webinar, “One Chart, Two Wins,” or book a strategy call.
