There’s a moment every risk adjustment professional has experienced: standing in a provider’s office with compliance reports in hand, watching a physician juggle an emergency, a waiting room full of patients, and now…you…asking for their attention on documentation standards.
In a recent roundtable discussion, a health plan coding and analytics leader described exactly this scenario. Instead of pushing through her agenda, she read the room, acknowledged the reality, and left. “I’ll be back when the timing is better,” she told the provider. That decision—to prioritize relationship over transaction—captures something fundamental about what actually works in provider engagement.
It’s not easy. And pretending otherwise does everyone a disservice.
The Documentation Gap Nobody Wants to Talk About
One of the toughest challenges health plans face isn’t coding complexity or regulatory interpretation (though these are real world challenges in their own right). It’s simpler and more frustrating: getting the medical records that should exist.
Claims data shows a high-risk condition documented by a specific provider on a specific date of service. The audit notice arrives. The retrieval process begins. And then the provider says they don’t have the chart.
This scenario plays out with uncomfortable frequency, and it raises questions that go beyond operational logistics. When a claim exists but documentation doesn’t, especially for high-risk conditions captured by only one provider, health plans face a critical decision point: How do you escalate? Who gets involved? What role does compliance play? And how do you help providers understand that chart maintenance isn’t administrative busywork…it’s the foundation of defensible risk adjustment?
These conversations are happening now in health plans navigating RADV audits. They’re uncomfortable, necessary, and long overdue.
“We’re in the space of multiple RADVs going on,” the plan leader noted, highlighting a shift that many organizations haven’t fully internalized. For plans operating multiple lines of business, the collision of simultaneous audits isn’t a hypothetical scenario. It’s the new baseline expectation.
This reality demands a fundamentally different approach to resource allocation. The traditional model of redirecting existing staff when an audit notice arrives is no longer viable. Organizations need standing capacity, clear prioritization frameworks, and contingency plans that account for worst-case scenarios where multiple audits overlap.
The Burden Is Real
Provider engagement in risk adjustment is challenging because the burden on providers is real. Acknowledging this isn’t weakness…rather the starting point for any strategy that will actually work.
Providers are aware of audit risks. They understand that documentation deficiencies have consequences. They’ve seen the retrospective chart review reports identifying incorrect code selection and missing clinical detail. The question isn’t whether they understand the stakes. The question is whether they have the capacity, tools, and support to do anything about it amid everything else they’re managing.
Health plans that succeed in provider engagement don’t minimize this reality. They lead with it.
“We understand that you are burdened” the plan leader explained. “We’re here as your partner, for support not to overburden you further.” This framing shifts the dynamic from enforcement to collaboration. It positions the health plan not as an auditor extracting compliance, but as an ally helping providers navigate a complex regulatory environment that affects them both.
Consistency, Clarity, and Conciseness
Providers need three things from their health plan partners, and none of them involve longer meetings or more paperwork.
Consistency in messaging. When health plans change priorities, tools, or expectations quarterly, provider trust erodes. The organizations seeing traction are those that pick a strategy, communicate it clearly, and stick with it long enough for providers to internalize and act on it.
Clarity about expectations. Providers don’t need to write novels. They need to document concisely and clearly…capturing whether conditions are active, reflected in the treatment plan, and appropriately detailed to demonstrate severity of illness. When health plans over-complicate documentation requirements, they create anxiety and resistance. When they simplify, they create action.
Connection to patient care. The most effective provider engagement strategies anchor documentation in what providers already care about: comprehensive patient care. A well-documented chart based on the member’s true clinical acuity doesn’t just satisfy CMS—it ensures the next clinician who sees that patient has complete information. It protects continuity of care. It reflects clinical reality.
Making that connection explicit helps providers see documentation not as a health plan requirement, but as a clinical imperative.
The Long Game
Building effective provider relationships in risk adjustment isn’t about perfect execution in every interaction. It’s about reading the room, respecting constraints, and showing up consistently over time.
The leader who left that provider’s office without delivering her report understood something crucial: she was playing a long game. Burning a relationship for one conversation wasn’t worth it. Coming back when the provider had capacity to engage would yield better results for everyone.
This approach requires patience, empathy, and organizational cultures that reward relationship-building over short-term metrics. It means measuring success not just in documentation rates, but in provider trust, engagement, and willingness to partner through audit cycles.
The health plans that will succeed in the intensifying audit environment aren’t necessarily those with the most sophisticated technology (though this certainly helps) or the largest compliance teams. They’re the ones that understand provider engagement is fundamentally human work…requiring empathy, consistency, and a genuine commitment to partnership over enforcement.
Because at the end of the day, providers don’t work with health plans because they have to. They work with health plans they trust to support them, understand their reality, and treat them as partners in delivering better care.
Invent Health provides risk adjustment technology solutions that support collaborative provider engagement and streamline documentation workflows for Medicare Advantage, ACA, and Medicaid health plans.
