Risk adjustment in PACE is getting more complex. With the transition to v28, the accelerated move to EDS-based submissions, and increasing enforcement activity, expectations around diagnosis accuracy, clinical relevance, and visit-based documentation are rising fast. The margin for error is shrinking (and the work required to get it right is growing).

That reality came into sharp focus this year with the $556M DOJ settlement involving Kaiser Permanente, which centered on diagnoses added after visits, retrospective record changes, and pressure on clinicians to document conditions that couldn’t be clearly tied to care delivered during the encounter — all in service of higher reimbursement.

PACE operates under a different model, but the takeaway is universal: Risk adjustment is getting more demanding, and the consequences of getting it wrong are real.

The pressure on PACE teams is real

No one in PACE is imagining this. Teams are being asked to:

• Navigate new coding models and submission requirements
• Capture increasingly detailed participant complexity
• Ensure diagnoses are clinically addressed and documented during the visit
• Maintain documentation that holds up months — or years — later

More documentation is part of the deal (that documentation ensures organizations are accurately reimbursed for the cost and complexity of participant care delivered).

But, more chaos doesn’t have to be.

This is where pre-encounter preparation (PEP) becomes essential.

What pre-encounter prep does (and why it matters)

At its core, PEP shifts risk adjustment upstream.

Instead of relying on retrospective chart reviews or post-visit cleanup, PEP brings the right information forward — before the visit — so clinicians walk in informed, focused, and ready to document care as it happens.

That timing matters.

The Kaiser case is a cautionary tale of what happens when documentation decisions drift after the visit. Even well-intentioned efforts can blur clinical judgment, introduce pressure, and create compliance risk.

Done well, PEP helps ensure that clinically appropriate complexity is addressed during the visit and documented in a way that supports accurate reimbursement.

PEP puts structure around the process:

• Preparation before the visit
• Clinical judgment during the encounter
• Documentation that reflects care delivered

IRIS is advancing PEP for today’s PACE reality

IRIS risk adjustment was designed from the start to support true PEP for PACE clinicians and care teams. And as risk adjustment gets more complex, PEP needs to get better right along with it.

With its most recent release, IRIS strengthens what PEP is meant to do: reduce noise, sharpen focus, and give teams real control over how they prepare (without adding work where it doesn’t belong).

It makes the complexity more manageable:

Cut the noise, see what matters

IRIS now delivers a cleaner, even more intuitive PEP experience that prioritizes relevance. Non–risk-adjustable conditions move out of the way, so clinicians can focus on participants and the most impactful opportunities, not long lists of maybes.

Work the way you want to

PEP should fit real workflows. IRIS lets teams prepare by participant, provider, or team, supports both digital and print-based review, and keeps PEP outside the exam room, where it belongs.

Always up to date

Clinicians can explicitly accept or reject suggested diagnoses based on clinical judgment. Those decisions stick, keeping PEP views current, focused, and free from repeat review.

To support this experience, IRIS combines NLP with onshore certified risk adjustment coders who identify and validate opportunities ahead of each assessment. Providers see a focused, visit-ready view, with full agency over what enters the encounter.

Meeting complexity with preparation (not pressure)

v28, EDS, and increased oversight aren’t just compliance challenges; they’re financial ones.

PACE organizations that succeed in this environment will be those that invest in better preparation before the visit, ensuring clinical complexity is addressed in real time and documented accurately. That’s how teams protect revenue, reduce risk, and support clinicians at the same time.

Risk adjustment is getting harder, and PEP is how PACE keeps up. With IRIS, that prep just keeps getting better.

Ready to see PEP in action in IRIS? Book a demo.