It was 4:47 PM on a Friday when Jenny from coding knocked on my door. She’d been reviewing charts for eight hours straight, part of our massive Q1 retrospective risk adjustment push. “I keep seeing the same thing,” she said, looking frustrated. “These diabetic patients all saw endocrinologists who documented neuropathy, but we coded them as diabetes without complications because the primary care notes didn’t mention it.”

That conversation led to us finding $4.2 million in missed HCCs over the next six weeks. Not through fancy technology or expensive consultants. Just by asking a simple question: why do we only trust certain doctors’ notes?

The Trust Hierarchy Nobody Talks About

Every health plan has an unwritten trust hierarchy for documentation. Primary care physicians sit at the top. Their notes get reviewed first, believed most, and coded fastest. Specialists come second, if we get to them at all. Hospital documentation? Third place on a good day. And anything from outside our network barely gets a glance.

This hierarchy made sense in 1995. Maybe even in 2005. But today, when specialists document with incredible detail and hospitals generate comprehensive assessments, we’re literally ignoring our best documentation sources because of outdated assumptions.

Here’s what kills me: specialists document better for risk adjustment than PCPs. It’s not even close. An endocrinologist describing diabetic complications includes lab values, medication responses, disease progression markers, everything CMS wants to see. The PCP note says “diabetes, stable.” Guess which one we code from?

The hospital blindspot is even worse. Every admission generates pages of detailed assessment, complete problem lists, specialist consultations. A single hospital stay documents more HCCs than six months of outpatient visits. But because hospital records are “complicated” to review, we skip them. We’re leaving millions on the table because PDFs are annoying.

The Convenience Trap

We’ve optimized retrospective review for convenience, not completeness. We review the easy charts, from familiar providers, in standard formats. Then we wonder why we’re missing 30% of legitimate HCCs.

I watched a coding team last month. They had two stacks: regular PCPs whose notes they knew, and everything else. Guess which stack got reviewed when deadlines hit? The familiar one. Every time. The stack with specialists, hospital discharges, outside records, that got pushed to “next quarter.” Next quarter never comes.

Electronic health records made this worse, not better. Now we can quickly pull all PCP notes with three clicks. Getting specialist records requires logging into different systems, requesting access, waiting for responses. So we don’t. We review what’s convenient and tell ourselves it’s comprehensive.

The vendor echo chamber reinforces these patterns. Most retrospective review vendors come from coding backgrounds. They’re comfortable with outpatient documentation. They’ve built their entire process around PCP notes. When you hand them specialist or hospital records, they struggle. So they tell you those records aren’t worth reviewing. You believe them because it’s easier than pushing back.

The Breakthrough Approach

After Jenny’s revelation, we flipped our entire retrospective process. Instead of starting with PCPs, we start with specialists. Instead of avoiding hospital records, we prioritize them. The results have been shocking.

Specialist-first review finds 40% more HCCs than PCP-first. Not because PCPs document poorly, but because specialists document conditions PCPs haven’t even diagnosed yet. That diabetic neuropathy? The PCP didn’t know about it. The kidney disease progression? First documented by nephrology. The heart failure classification? Cardiology caught it months before the PCP.

We built what I call “documentation heat maps.” For each member, we identify who’s actually treating their complex conditions. If someone sees cardiology monthly but their PCP annually, we review cardiology notes first. Sounds obvious now. Took us years to figure out.

Hospital record prioritization changed everything. We now review every admission and emergency visit before touching routine office visits. One hospital stay equals about 20 office visits in terms of HCC opportunity. The documentation is dense, sure. But it’s also complete, detailed, and defensible.

The Monday Morning Change

You can start fixing this Monday without buying new technology or hiring consultants. Pull 10 random members with specialist visits. Review the specialist notes first, then compare to what you coded from PCP records. I guarantee you’ll find missed opportunities.

Next, grab 5 members who were hospitalized last year. Review their discharge summaries and admission H&Ps. Compare that to their outpatient coding. The gaps will make you sick, in a good way, because now you know they exist.

Stop letting convenience drive your retrospective strategy. The easiest documentation to review isn’t the most valuable. The providers you’re most comfortable with aren’t documenting the most complex conditions. The records that are hardest to get often contain the most revenue.

Jenny’s Friday afternoon observation saved us millions. Not because she discovered new technology or revolutionary methods. She just noticed we were looking in the wrong places. Your team has probably noticed the same patterns. The question is: are you listening to them, or are you too busy reviewing the same convenient charts that miss the same valuable HCCs every single year?