From Retrospective to Prospective: The Shift That Changes Everything in VBC

Stepping into value-based care, provider leaders face a pivotal choice: stay tethered to yesterday’s charts and after-action audits, or adopt technologies that meet clinicians at the point of care, every day.

For years, risk adjustment relied on looking back. Teams often sifted through patient records months after visits, patching diagnoses and hunting for missed documentation. This method "worked” for a fee-for-service world, where paperwork could trail care delivery. Now, with value-based care (VBC) and regulatory moves like the No-UPCODE Act, the industry finds itself at a turning point.

In value-based care, timing isn’t just a detail; it’s the difference between reacting and leading.

The Retrospective Trap
‍

Retrospective coding and chart review forces clinical teams to play catch-up. Sifting through irrelevant suspect lists or combing records for risks long after the patient has left is exhausting. The real cost? Missed opportunities for intervention, mounting provider burnout, and revenue left on the table when conditions go unrecognized until it’s too late.

Retrospective risk workflows are inherently defensive. They chase gaps after the moment for meaningful intervention has passed. Chronic conditions might go unaddressed until late in the year. The administrative burden of chasing down data and reworking incomplete documentation weighs on providers, CDI professionals, and coders. For risk-bearing groups, this leads to missed opportunities for holistic patient management, and often, an incomplete clinical profile that skews reimbursement and population health strategy. ‍

Why Proactive, In-Workflow Intelligence Matters
‍‍

A prospective approach flips this experience and transforms the dynamic. By embedding intelligence directly into the workflow — before, during, and immediately after patient encounters — organizations move from reactivity to anticipation. Providers gain real-time visibility and clarity into the patient’s risk profile. Chronic conditions and care gaps are surfaced more naturally as part of routine care, allowing clinical teams to address documentation, identify new conditions, and close gaps when it counts most.

Risk and quality leaders rarely operate with surplus staff or endless hours. Efficiency isn’t a “nice to have”; it’s the only way to keep pace with changing policy, increasing complex patient needs, and tighter financial benchmarks. Clinicians do not need another sea of generic pop-ups but instead require context-aware advisories that reflect the actual encounter, empowering action while minimizing alert fatigue.  

Technologies now allow productivity to soar: AI-powered workflows deliver faster gap closure, increase in address rate, and millions in annual revenue recapture. For example, CDI teams, doubled their output in just twelve weeks by focusing expertise where it matters and bypassing manual spreadsheet reviews entirely.

Prospective risk adjustment is about more than operational efficiency; it changes what’s possible for quality improvement and population health teams. Data fragmentation declines because workflows connect clinical intelligence across visits and providers. Decision making gets stronger: teams see which gaps are open, why, and what action is needed; without backtracking or relying on guesswork months later. Early engagement with high-risk groups becomes the norm, not the exception.

The bottom line: Why is prospective risk adjustment better than retrospective?

Prospective Risk Adjustment captures patient risk and documentation requirements in real time, at the point of care, allowing for immediate action and audit-ready data. Retrospective Risk Adjustment relies on post-visit chart reviews and coding months later, which leads to missed clinical opportunities, administrative burden, and potential non-compliance under new VBC regulations. ‍
‍

Provider Workflows and the Reality of Compliance
‍

Keeping pace with every new regulation, from emerging HCC risk models to the new requirements proposed in the No-UPCODE Act, is no longer optional. The Act’s limits on risk adjustment sources and retrospective codes mean that every provider must capture high-risk diagnoses in real time, or risk missing out on proper payment and exposing themselves, their organizations, to audit scrutiny.

Providers require systems engineered for audit-ready compliance. Dynamic validation checks, clear audit trails, and embedded educational prompts ensure coding precision each step of the way. The goal: eliminate unwarranted denials, prevent missed incentives, and create peace of mind for clinicians and VBC leaders alike; from the point-of-care to the CMO, the VP of Population Health, and the CDI leader.

Preparing for Tomorrow: Future-Proofing VBC
‍

There’s more at stake as compliance standards tighten. The No-UPCODE Act draws a clear line: only diagnoses captured at the point of care, and in real time, are likely to be honored for risk payment. Chart reviews and post-visit coding, long considered valuable safety nets, may no longer meet payment or audit standards. The era of cleaning up risk scores after the fact is ending. The writing on the wall signals a broader expectation: prospective intelligence should be standard, not a luxury.

Legislation shifts like the No-UPCODE Act brings sharp clarity to what matters: refocusing care on the moment in which it occurs. Providers who automate prospective risk adjustment and post-visit clinical validation prior to claims submission are poised to meet new standards head-on. Automations must be supported by traceable evidence. Transparency isn’t just a buzzword; it’s the foundation for regulatory peace of mind, smoother audits, and maximum funding integrity.

Industry consensus around the No-UPCODE Act suggests a paradigm shift: prospective is now essential. Provider organizations best positioned for success will act on this signal, embedding intelligence in the workflow and shaping risk programs to meet VBC demands: accountability, timeliness, and impact with every patient and every visit. ‍

Top Recommendations for Risk & Quality Leaders
‍

• Embed audit-ready, evidence-backed clinical intelligence in every workflow. Surface only what is actionable and relevant, eliminating wasted chart mining.

• Invest in solutions with proven ROI, compliance precision, and scalability across diverse EHRs and practice environments.

• Prioritize provider education: clarify what matters in value-based care, so each prompt builds trust, not noise.

• Align analytics and reporting tools to real-world performance goals: gap closure rates, address rate improvement, RAF accuracy, and Star Ratings uplift.

• Future-proof compliance by adopting technologies that anticipate regulatory shifts, steering clear of dependence on retrospective coding or after-the-fact review.

‍

Leaning into prospective risk workflows requires fresh thinking and new systems. Leaders must move beyond familiar habits and build frameworks that prioritize delivery of intelligence at the right-time, in right-place. The result: clinical teams can act confidently, knowing they’re managing risk where it matters most: at the intersection of data and patient care, not in the rearview mirror.

The next chapter for value-based care technology will be shaped by those who pivot decisively toward prospective risk adjustment. The old playbook of endless retrospective review, stacks of suspect lists, and frantic pre-audit fixes cannot deliver the clinical, financial or audit outcomes required in today’s landscape. That’s a future few can afford to chase.

‍

Authored by Marena Hildebrandt, DNP, RN, PHN, NEA-BC
Product Marketing Manager, Provider Solutions, Reveleer