Care Decoded Insights — Featuring Subbu Ramalingam & Dr. Sunil Nihalani
Risk adjustment documentation is entering a pivotal moment. What used to be a backend, retrospective clean-up exercise is now becoming one of the most strategic levers for care quality, Stars performance, audit readiness, and patient experience.
On this episode of Care Decoded, host Dr. Sunil Nihalani sits down with Subbu Ramalingam, a former health plan executive and national expert on Stars, risk adjustment, and healthcare quality. Together, they explore why accurate documentation is no longer just a compliance task — it’s a clinical responsibility that shapes outcomes, equity, member experience, and the financial sustainability of health plans.
This blog breaks down the major insights from the conversation and explains what healthcare leaders should do now as CMS tightens oversight, RADV audits expand, and real-time clinical AI becomes part of modern documentation workflows.
Most stakeholders still think about Stars and risk adjustment as separate functions — quality lives on one side, financial accuracy on the other. But as Subbu points out, this separation is misleading:
“Risk adjustment is about delivering the right care to people. Documentation is what lets the entire system understand what a patient actually needs.”
Accurate documentation:
Determines clinical eligibility for screenings
Ensures members fall into the right HEDIS denominators
Drives provider workflows
Enables correct plan payments
Influences which benefits a member can access
Impacts outcomes, especially for chronic conditions
When diagnosis coding is missing or incorrect, everything downstream breaks — from care coordination to prior authorization to quality measures.
Members don’t wake up caring about RAF scores or Stars. They care about:
How fast they can get care
Whether referrals go through
Whether transportation benefits work
Whether care teams communicate clearly
Whether the process feels easy or frustrating
Yet documentation determines whether the system even recognizes the member’s needs.
Sunil explains it well:
“Patients don’t realize CMS is doing this to help them get better care. It’s not about numbers. It’s for their health.”
If a condition isn’t documented:
A referral may be denied
Care gaps may not trigger
Plans cannot offer accurate benefits
Members face unnecessary appeals
Care is delayed
Risk adjustment documentation translates clinical reality into operational reality.
Subbu uses diabetes as the perfect example.
From a quality perspective:
A1C control
Kidney health
Eye exams
From a risk adjustment perspective:
A chronic condition that impacts RAF
Requires annual recapture
Provides signals that drive care coordination
If coding is wrong — either overcoded or undercoded — quality measures fail, revenue is misaligned, and members don’t get the care they need.
This is why documentation and quality teams must stop operating in silos.
The industry is moving fast from:
Retrospective chart reviews
Manual cleanup
Year-end pressure
to:
Prospective documentation
Real-time clinical validation
Integrated EMR workflows
Immediate feedback to providers
As Subbu says:
“It all starts with the visit. You can’t close gaps in care if the documentation isn’t correct in real time.”
This is where real-time documentation integrity solutions (like Inferscience’s Chart Assistant) become essential.
Prospective validation enables:
Accurate and complete diagnoses
Real-time MEAT validation
Identification of incorrect or outdated codes
Point-of-care guidance
Gap closure tied directly to chronic conditions
Retrospective-only strategies are no longer viable — not in a RADV-heavy environment.
CMS has announced:
Hiring ~3,000 coders
Reopening multiple years of RADV audits
New requirements for rapid diagnosis deletes
Review of 2023 dates of service
Expanded sampling across plans
This is not a routine update — it’s a systemic shift.
Subbu is candid about the stakes:
“For some plans, this is an existential question. If billions get clawed back, can they stay in business?”
For leaders, this means:
Documentation must be supportable and specific
Deletes must be handled quickly
Provider communication must improve
Documentation noise must decrease
Real-time validation must replace guesswork
High-volume coding without clinical specificity is no longer acceptable.
Incorrect coding affects much more than payments.
Subbu gives a real-world example:
Members with cancer often need enhanced food or transportation benefits
If the plan’s documentation misses cancer diagnoses
Funding drops
Benefits shrink
Members lose access to services they urgently need
On the other hand, overdocumentation leads to:
Inflated payments
Future benefit cuts
Damaged trust
Increased scrutiny and OIG exposure
Documentation integrity protects plan sustainability and member experience.
Subbu outlines a balanced scorecard approach for risk adjustment documentation.
Member visit rate
Recapture rate for chronic conditions
Condition accuracy
Submission timeliness
Provider-payer leakage
Accuracy of documentation at the point of care
Diabetes control
Kidney health
Medication adherence
Preventive screenings
Medical Loss Ratio (MLR)
Avoidable ER visits
Readmissions
Sunil emphasizes that MLR is a powerful directional measure:
“MLR tells you if you’re documenting accurately and managing care well.”
Subbu offers clear guidance for leaders who want to elevate risk adjustment documentation from compliance to strategic advantage:
Documentation integrity should appear seamlessly in the EHR — not in a separate system.
The future is accuracy, not more codes.
Insights from home assessments, pharmacy data, and chart reviews must flow to the PCP.
AI should support specificity, not inflate codes.
Every code is a clinical decision.
Every code tells a story.
Every story drives care.
This is exactly where Inferscience creates value:
Identify missed, outdated, or incorrect diagnoses during the visit.
Reduce the need for retrospective chases.
Ensure documentation meets CMS expectations.
Tie chronic conditions to related screenings and close gaps in one pass.
Deliver actionable insights from plans to providers — and back.
Leaders who operationalize these tools will stay compliant, improve care, and better support their members.
Risk adjustment documentation is no longer administrative. It’s the backbone of accurate care, Stars performance, financial stability, and patient trust.
As Subbu says:
“Deliver meaningful care. Everything else starts there.”
To explore these insights in depth, listen to the full episode of Care Decoded, where Dr. Nihalani and Subbu unpack how documentation accuracy becomes the foundation for better outcomes across the entire care ecosystem.
