Health plans and risk-bearing providers are investing heavily in prospective risk adjustment strategies, embedding HCC capture into annual wellness visits, deploying clinical staff into PCP offices, and training providers on documentation best practices. These efforts are important, but they’re not enough.

Even the most robust prospective programs leave meaningful gaps that retrospective risk adjustment is uniquely positioned to fill.

1. Prospective Efforts Focus on Primary Care - Retrospective Captures the Rest

Most prospective risk adjustment programs operate through primary care workflows. But patients interact with the healthcare system in many ways—especially those with complex conditions. Retrospective coding reviews bring in the full picture by capturing diagnoses documented by specialists, hospitals, behavioral health providers, and more.

2. Many Diagnoses Fall Outside the Scope of Primary Care

While PCPs play a central role in managing patient care, many high-value or complex diagnoses—such as certain cancers, neurological disorders, and autoimmune conditions—are typically diagnosed by specialists or during hospital stays. This also includes serious mental health conditions like schizophrenia, bipolar disorder, and substance use disorders, which are usually documented by psychiatrists or behavioral health providers. These diagnoses may not be appropriate for a PCP to code independently and often do not appear in prospective workflows. Retrospective review ensures they are captured accurately from the appropriate source.

3. Retrospective Is a Quality Check on Your Prospective Program

Retrospective review is how you measure the effectiveness of your prospective strategy. It helps answer critical questions:

• Are diagnoses being captured as expected?

• Are providers documenting with sufficient specificity?

• Are there missed opportunities due to time constraints or provider variability?

Without retrospective review, there’s no structured way to validate and refine your prospective workflows.

4. Prospective Doesn’t Cover your whole Provider Network

Within any network, some providers will not participates in prospective programs. Some are out-of-network. Others may not follow documentation guidance. Retrospective review acts as a safety net to capture risk from non-participating or lower-performing providers.[1] 

5. Retrospective Review Strengthens Compliance

Retrospective review can improve coding accuracy and compliance by identifying patterns of over- or under-documentation. It helps reinforce adherence to CMS guidelines and supports defensible audit trails.

 The Bottom Line

Prospective and retrospective risk adjustment aren’t in competition—they’re complementary. The most successful organizations use retrospective review not just as a backup plan, but as a critical part of a closed-loop strategy that strengthens risk capture, improves accuracy, and drives better performance under V28 and beyond.

At HealthMC, we help payers and providers ensure their risk adjustment strategies are complete, compliant, and future-proof. Even when prospective programs are strong, retrospective review remains essential.

This is a weird framing.  I don't think everyone tries to get everyone to participate in prospective.  We should reframe simply as prospective doesn't hit your whole provider network.