By Jeannie Hennum, General Manager of Value-Based Care at Verisma
May 7, 2026
Healthcare is in the middle of a seismic shift. The old fee-for-service model – where providers are paid for every test, visit and procedure – is giving way to something more intentional: value-based care (VBC). While much of the conversation around VBC focuses on clinical outcomes and payment models, there’s a critical operational challenge that doesn’t get enough attention: how we retrieve and manage medical records.
Getting the right chart, from the right place, at the right time isn’t just an administrative task – it’s mission-critical for the financial health and clinical accuracy of every organization operating under a value-based model.
VBC record retrieval is a revenue integrity and risk-control function. Strong retrieval and documentation support can:
- Protect risk-adjusted payments tied to risk adjustment factor (RAF)/hierarchical condition categories (HCC) capture
- Improve quality program payouts by ensuring evidence is found and submitted on time
- Reduce recoupment and audit exposure from unsupported diagnoses or missing information
Put simply: better records = fewer dollars left on the table and fewer dollars clawed back.
What Is VBC, Really?
At its core, VBC is the evolution of how care is delivered and who takes on the risk. It’s a move away from treating conditions in isolation and toward whole-person health. Instead of standardized care plans, the goal is personalized prevention. Instead of volume, the focus is on quality – ensuring services lead to positive health outcomes, improved patient experience, and reduced costs.
Chief financial officers (CFO) can evaluate every VBC program by focusing on these variables:
- Revenue (risk-adjusted payments, shared savings, incentives)
- Cost (labor and vendor cost to retrieve/validate charts)
- Risk (recoupments, audit failures, penalties)
- Cash (how fast you can close the loop before submission deadlines)
Record retrieval touches all four.
Under VBC, providers are rewarded through incentive-based programs for meeting specific quality measures. That means reduced readmissions, better care transitions, and higher patient satisfaction aren’t just nice-to-haves – they translate into performance dollars (bonuses, shared savings, and risk-adjusted payments) only if the supporting documentation is retrieved, validated and submitted on time.
ACO LEAD: The Next Chapter in VBC
While accountable care organization (ACO) realizing equity, access, and community health (REACH) has been a proving ground for provider organizations with VBC expertise, the Centers for Medicare & Medicaid Services (CMS) is looking ahead. The long-term enhanced ACO design (LEAD) model is set to launch January 1, 2027, and represents a significant evolution in how ACOs will operate over the next decade.
What Makes LEAD Different?
ACO LEAD is designed as a 10-year model from 2027–2036, a sharp departure from the shorter program cycles characterizing previous CMS initiatives. That long horizon isn’t just symbolic, it’s structural. Here’s what sets it apart:
- Fixed 10-year benchmark with no rebasing. One of the biggest pain points in existing models is benchmark volatility. When benchmarks reset, organizations that have driven down costs can be penalized for their own success. LEAD eliminates that problem by locking in benchmarks for the full model term, giving ACOs predictability and long-term financial clarity.
- Lower participant alignment minimums. REACH required a scale many smaller and rural practices couldn’t meet. LEAD lowers the bar, making the model accessible to a broader range of provider organizations – including those in underserved and rural populations standing to benefit most from coordinated VBC.
- CMS-administered specialty risk arrangements (CARA). Under REACH, managing specialty care coordination was a significant burden on participating ACOs. LEAD introduces CARA, where CMS takes on the administration of specialty risk arrangements, easing the operational complexity for participants and allowing them to focus on primary care coordination and quality improvement.
Why LEAD Matters for Chart Retrieval
For organizations involved in medical record retrieval and risk adjustment, LEAD’s 10-year stability changes the calculus. With fixed benchmarks, the accuracy and completeness of documentation become even more critical financially. Every RAF score, care gap closure, and quality measure submission compounds over a much longer timeline – meaning small misses can become recurring revenue leakage, and small improvements can create recurring upside.
Organizations investing in scalable, accurate retrieval infrastructure are positioned to protect risk-adjusted revenue (PMPM), strengthen quality program performance dollars, and reduce avoidable recoupment exposure across the full decade of the model. Those treating retrieval as a short-term compliance exercise may find themselves locked into a 10-year program without the operational foundation to sustain financial performance.
Preparing for 2027
The January 2027 launch may feel distant, but the contracting, technology deployment, and workflow redesign required to participate effectively take time. Organizations considering LEAD should be asking themselves:
- Is our record retrieval centralized and scalable enough to support a 10-year commitment?
- Do we have the provider relationships and re-engagement processes to ensure documentation completeness?
- Are we shifting toward prospective retrieval strategies aligning with how LEAD will measure and reward performance?
- Do we know our current cost-to-collect a compliant chart (internal labor + vendor fees), and have we modeled the ROI of improving retrieval speed and completeness against expected incentive revenue and avoided recoupments?
The transition from REACH to LEAD isn’t just a program change. It’s a signal CMS is betting on long-term, stable partnerships with provider organizations. The organizations preparing early will be the ones best positioned to thrive.
ACO REACH vs. ACO LEAD
Key Comparison Takeaways
- Stability vs. agility: REACH rewards organizations performing in shorter cycles. LEAD rewards sustaining performance over a decade, a fundamentally different operational challenge.
- Accessibility is expanding: By lowering alignment minimums, LEAD opens the door to community health centers, rural practices, and smaller provider groups effectively excluded from REACH.
- Administrative burden is shifting: With CMS taking on specialty risk arrangements through CARA, participating ACOs can redirect resources from coordination overhead toward quality improvement and documentation accuracy.
- Retrieval stakes are higher: A fixed 10-year benchmark means early documentation gaps echo across the model term. Organizations need retrieval processes that are accurate and continuously improving.
Why RAF Scores and Care Gaps Matter
RAF scores are the engine behind VBC payment accuracy. Here’s how they work:
- Diagnoses (ICD codes), along with demographic and enrollment data, feed into HCCs.
- Conditions are grouped by cost severity, and hierarchical logic ensures the most severe condition is counted.
- Each HCC carries a relative risk weight, and the final RAF score combines demographic factors with those weights.
If the documentation supporting those diagnoses is incomplete, inaccurate or missing, the RAF score doesn’t reflect reality – or the payments. In simple terms, risk adjustment is a math problem: base rate × RAF. When RAF is understated, revenue is understated; when diagnoses are unsupported, the organization is exposed to audits and repayment. Care gaps go unidentified. Quality measures like MIPS and HEDIS fall short. The downstream effects ripple through the entire care model.
One useful way to size the opportunity is to model RAF sensitivity: even a 0.01 shift in average RAF, multiplied across thousands of covered lives, can become material annual revenue – especially in capitated arrangements.
Finding the Right Data: Retrospective, Prospective and Concurrent
Record retrieval in VBC isn’t one-size-fits-all. Organizations need to understand three distinct approaches:
- Retrospective Risk Adjustment: looks backward at diagnoses and costs from the same period. Often identifies missed capture too late to influence current-year cash flow and can increase fire-drill labor cost near deadlines.
- Prospective Risk Adjustment: uses past data to predict future costs (e.g., a 2025 diabetes diagnosis increases the 2026 payment rate). Protects next-year PMPM by ensuring complete, compliant diagnosis support is retrieved and submitted within the measurement window.
- Concurrent Risk Adjustment: uses current-year diagnoses to adjust current-year payments real-time (e.g., a new cancer diagnosis in March raises the risk score for that same year). Speeds cash realization but raises the bar on operational cycle time, retrieval delays can directly delay or reduce payment.
A shift toward prospective record requests is already happening. Organizations relying solely on retrospective retrieval are leaving money, and clinical accuracy, on the table.
Becoming a Forensic Medical Record Retrieval Expert
Medical charts live in a surprising number of places: archival storage, filing cabinets, multiple electronic medical record (EMR) systems, third-party platforms, and more. The distribution methods are equally varied – health information exchanges (HIE), portals, email, fax, mail, and on-site retrieval play a role.
Effective retrieval requires understanding:
- Where records are stored and how to access them across fragmented systems
- Plan, provider, and third-party relationships affecting availability
- Privacy and security requirements, including minimum necessary standards and patient self-pay protections
- Recoupment risk and the resources needed to manage it
Data fragmentation is real, and it’s one of the biggest obstacles to accurate VBC reporting.
Strategic Best Practices
So how do organizations get ahead of these challenges? A few key strategies:
- Centralize record storage and retrieval: to enable timely, complete submissions.
- Consider outsourcing, but plan: Contracting takes time, and policies may require a request for proposal (RFP) process.
- Embrace workflow automation but be realistic about deployment timelines: New technology is powerful, but it can take time.
- Don’t forget vendor management: Even the best tools and partners need collaboration.
Watch out for Pitfalls
Even with strong processes in place, retrieval comes with inherent financial risks: incomplete charts (lost measure credit and revenue), misplaced pages and missing signatures (denials), PHI mishandling (incident cost), excessive retrieval fees (higher cost-to-collect), purged records (permanent revenue leakage), and provider hardships delaying turnaround time.
Validation is essential. Provider re-engagement is critical when records come back incomplete. Share the “why” with your teams and partners. Missing information can lead to unsupported diagnoses, inaccurate coding, audits, and recoupments – real dollars, not abstractions. Time is of the essence, and collaboration makes the difference.
Leverage AI and QA
Integrating artificial intelligence (AI) into record retrieval and chart validation accelerates processes, flags inconsistencies, and streamlines data management. Maintaining a human-in-the-loop is essential for ensuring nuanced quality assurance (QA), especially when reviewing complex medical documentation or resolving ambiguous cases. Combining AI-powered automation with experienced human oversight creates a robust, reliable workflow maximizing efficiency and safeguarding accuracy.
Prioritize Archival for Compliance and Continuity
Establishing a secure, organized archival system for medical records is crucial. Proper archival supports audit readiness and regulatory compliance and preserves historical data for future analysis and ongoing patient care. Pairing advanced archival tools with thoughtful procedures, ensures records are accessible, protected and available when needed most.
The Bottom Line
VBC continues to evolve, and with it, the demands on how we collect, manage and use medical records. The organizations thriving will be those treating chart retrieval not as a back-office function, but as a CFO-visible lever for revenue (risk adjustment and incentives), cost (lower cost-to-collect), risk (fewer recoupments and audit findings), and cash (faster submission cycles).
The shift from retrospective to prospective record retrieval is happening now. Continuity of care through referrals and provider-based retrieval is expected to grow. And record retrieval? It’s not as easy as you might think. But this mission-critical capability is one of the clearest ways to reduce revenue leakage, strengthen quality payouts, and avoidable clawbacks – one record at a time.
Ready to strengthen your VBC performance? Contact Verisma to learn how our solutions improve record retrieval, support accurate coding, and drive aligned incentives for better outcomes. Let’s discuss your goals and how we can help, today.