May 15, 2025
Why Risk Adjustment Isn’t Just for Payers Anymore:
The Hospital Revenue Opportunity No One's Talking About
Hospitals are sitting on an untapped revenue opportunity—and it’s hiding in their documentation.
For years, risk adjustment models like CMS-HCC have been the focus of payers and primary care groups. But with the rise of value-based care, ACOs, Medicare Advantage, and hospital-owned physician groups, the conversation is shifting. Risk adjustment is no longer just a payer game. It’s a strategic imperative for hospitals—and CDI leaders are uniquely positioned to lead the charge.
Hospitals are increasingly held accountable for quality outcomes and costs. Programs like Medicare Shared Savings, Bundled Payments, and Health Equity Index measures tie performance and reimbursement to accurate patient acuity reporting. The only way to prove that a patient is as complex as they truly are? Precise, complete documentation.
In other words: If it isn’t captured, coded, and reported—it doesn’t count.
Clinical Documentation Integrity (CDI) programs have traditionally focused on inpatient MS-DRG optimization and denial prevention. But the same CDI teams can—and should—apply those principles to risk-adjusted populations across care settings.
- Capturing HCCs and chronic conditions on every encounter
- Ensuring specificity in documentation to reflect true patient complexity
- Supporting accurate quality and safety metrics (e.g., PSIs, mortality, readmissions)
With hospitals increasingly managing at-risk contracts or working within ACOs and MSSP frameworks, this isn’t optional anymore—it’s strategic.
“We’ve seen hospitals with strong CDI programs increase RAF scores, improve Star Ratings, and reduce denials—simply by shifting focus upstream,” says Rachel Mack, CDI Consultant at UASI.
What Hospitals Are Missing Without It:
- Revenue Leakage: Missed HCCs = missed dollars in risk-based models.
- Audit Vulnerability: Incomplete documentation makes hospitals an easy target for RADV and OIG audits.
- Reputation Risk: Quality metrics based on faulty data can distort a hospital’s actual performance.
- Poor Alignment with Medical Staff: Providers don’t always understand how much documentation impacts hospital performance.
