Every Medicare Advantage plan, most Medicaid managed care plans and a growing number of commercial plans send network practices a care gap list in the first quarter: patients attributed to your practice who have not yet had a colorectal cancer screening, a diabetic eye exam, a blood pressure reading in control, a mammogram, or whatever else the plan is measured on for the year. The lists arrive as spreadsheets, portal downloads or faxes. In most practices they are opened, found to be long and partly wrong, and set aside.
That is a mistake for two reasons. The first is patient care; a gap list is a reminder that a patient with diabetes has not had an A1c in a year. The second is money. Plans pay for closed gaps through quality bonus programs, shared savings and Star-linked incentives, and the payments are meaningful for a primary care practice. The window matters too. A gap closed in May can be documented, coded, submitted and reconciled before the plan's year-end data cutoff. A gap first addressed in December is a scramble.
This is the process we run with practices in the second quarter, including the practices we support under our closing gaps in care service.
Key takeaways
- A third to a half of the gaps on any plan list are already closed or belong to patients who are not yours. Reconcile against the EHR before anyone makes a call.
- Blood pressure and A1c close inside a normal visit and are heavily weighted in Star Ratings. They come first.
- A gap closed clinically but never sent to the plan is not closed for the incentive. CPT Category II codes on the claim and structured results, not scanned PDFs, are what make closures count.
- Combine gaps into one visit and script the outreach as care, not compliance. A weekly protected block beats a December sprint.
Step one: reconcile the lists against your own data
Plan gap lists are built from claims, which lag and miss things. A meaningful share of the gaps on any list are already closed: the screening was done at a facility that billed the plan under a different NPI, the patient is no longer yours, the patient had the test and it was recorded as a result without a billed CPT code. Before anyone calls a patient, run each list against the EHR:
- Match patients. Remove those who are deceased, transferred or never seen.
- For each remaining gap, check the chart for evidence of closure: a result, a consult note, a procedure report, an immunization record.
- Where the closure exists but was never sent to the plan, submit it. Most plans accept supplemental data (a chart extract, a standard form or a CPT Category II code on a zero-dollar claim) for exactly this purpose.
- What remains is your real outreach list. It is usually a third to a half of the original.
Keep the reconciliation in one spreadsheet per plan with a column for the outcome of each row: already closed and submitted, not our patient, or open. That sheet is what you compare against the plan's next list, and it is what proves your closure rate if the plan's year-end numbers do not match yours.
Step two: prioritize by measure and by payer
Not all gaps are equal. Some measures are triple-weighted in Star Ratings and carry the most incentive. Some are easiest to close in the office. Our usual order for a primary care practice:
| Measure (HEDIS abbreviation) | How it closes | Coding that counts |
|---|---|---|
| Controlling High Blood Pressure (CBP) | A blood pressure under 140/90 documented at a visit; the most recent reading of the year counts | CPT II: 3074F or 3075F (systolic under 130 or 130 to 139) and 3078F or 3079F (diastolic under 80 or 80 to 89) |
| Glycemic Status Assessment for Diabetes (GSD) | An HbA1c result; the most recent of the year counts | CPT II: 3044F (under 7.0), 3051F (7.0 to 7.9), 3052F (8.0 to 9.0), 3046F (over 9.0), plus the lab CPT 83036 |
| Eye Exam for Patients With Diabetes (EED) | Retinal exam by an eye professional or retinal imaging | 2022F, 2023F, 2024F, 2025F, 2026F, 2033F as documented, or 92250 for imaging |
| Colorectal Cancer Screening (COL-E) | Colonoscopy, FIT, FIT-DNA, CT colonography or sigmoidoscopy within the look-back for each | Procedure or lab code, or supplemental data from the performing facility |
| Breast Cancer Screening (BCS-E) | Mammogram in the last 27 months | 77067 or supplemental data |
| Kidney Health Evaluation for Diabetes (KED) | eGFR and uACR in the same year | Lab codes; both tests required |
Blood pressure and A1c close inside a normal visit, which is why they come first. If the patient is on the schedule anyway, the visit template should prompt for the reading, the result and the Category II code. Colorectal screening is the slowest to close because it depends on a referral and a facility, so start those conversations in the spring even though the closure will land in the fall.
Prioritize by payer too. Ask each plan what its program pays and when its data cutoff falls. A plan that pays per closed gap with a cutoff in early December deserves the first outreach hours; a plan that pays only on a year-end rate that your practice is already clearing deserves fewer.
Step three: make closures count
A gap that is closed clinically but never reaches the plan is not closed for the incentive. Three habits make the difference. First, the CPT Category II codes above go on the claim as zero-dollar lines; most payers accept them and a few require them. Second, results from outside labs and facilities are entered as structured data, not scanned PDFs, so the EHR quality report and the supplemental data file can find them. Third, one person reconciles the plan's updated gap list against your closure log each month and chases the ones the plan still shows open.
The blood pressure measure is where practices lose the most closures they earned. The most recent reading of the year is the one that counts, so a patient controlled in May and elevated at a December sick visit is a gap again. Retake an elevated reading after five minutes and document the lower value if that is what the retake shows; the measure allows the lowest systolic and lowest diastolic from the visit. Train the medical assistants on that rule specifically.
Step four: run outreach that works
Outreach is where most gap programs stall, because it competes with the phones. What works in the practices we support is a short weekly block: a medical assistant or care coordinator works the prioritized list for a set number of hours, using the plan's attribution list to confirm coverage, and books the patient into a slot the practice has reserved for gap closure visits. Text first, then a call. Script the reason as care, not compliance: "It has been over a year since your last diabetes labs and Dr. Reyes would like to see you." Log every attempt in the EHR so nobody calls the same patient twice.
Combine gaps. A 68-year-old patient with diabetes on the list for A1c, eye exam, kidney evaluation and colorectal screening needs one visit and two referrals, not four calls. Build the visit around all of them: the A1c and the eGFR and uACR are drawn at the visit, the retinal imaging is done in the office if you have the camera or the ophthalmology referral is placed before the patient leaves, and the FIT kit goes home with them. Four gaps, one appointment.
What a quarter of gap work looks like
Here is the second quarter for a four-provider family medicine practice we support, with the numbers rounded. It is one practice and one payer mix, so treat it as a shape rather than a benchmark.
| Item | Number | Note |
|---|---|---|
| Gaps on plan lists received in Q1, all plans | 2,140 | Six plans, spreadsheets and portal downloads |
| Removed in reconciliation (not our patient, already closed in chart) | About 900 | Roughly 40 percent; closures already in the chart were submitted as supplemental data |
| Real outreach list | About 1,240 | Sorted by measure weight and plan cutoff |
| Weekly outreach block | 6 hours | One medical assistant, Tuesday and Thursday afternoons |
| Patients reached and booked per week | About 35 | Text first, call second; roughly two attempts per booking |
| Gaps closed per booked visit | About 2.3 | Because visits were built around every open gap for that patient |
| Gaps closed April through June | About 1,000 | Including the supplemental data submissions from reconciliation |
The number that surprised the practice was the 2.3 gaps per visit. Building the visit around all of a patient's gaps, rather than the one the plan happened to list first, is what made six hours a week enough. The second surprise was how much of the quarter's progress came from reconciliation alone, before a single patient was called.
Where PCMH fits
Practices with PCMH recognition already have most of this: a registry, a care coordinator, a QI process and a habit of measuring. Gap closure is the same work pointed at the measures the plans pay for, and the evidence it produces (stratified reports, outreach logs, results shared with the team) doubles as annual reporting evidence for the QI and KM criteria under the current version 11.1 standards.
Questions we hear
The plan's list shows patients we have never seen. What do we do with them?
Send them back with a note. Attribution errors are common, and a plan that does not correct its list will hold you responsible for patients you cannot reach. Keep a copy of what you returned and when.
How much is a closed gap worth?
It depends entirely on the plan's program, and we do not quote figures because contracts vary so widely. Ask each plan for the current year's incentive terms in writing. Some pay per closed gap; some pay on the practice's rate at year end; some pay through shared savings. Know which before you decide how many hours to invest.
Can this be outsourced?
The reconciliation, the coding review and the reporting can. The visit cannot, and the outreach works best from a number patients recognize. Our closing gaps in care service handles the list work and reporting and leaves the patient contact with the practice or shares it, and the same data feeds our PCMH annual review for recognized practices.
What to do this month
- Gather every gap list received since January into one folder and reconcile each against the EHR before any outreach.
- Submit supplemental data for every closure that is in the chart but not on the plan's list.
- Ask each plan, in writing, for its incentive terms and its year-end data cutoff, and sort the outreach list by those answers.
- Add the CPT Category II prompts for blood pressure and A1c to the visit template and brief the medical assistants on the retake rule.
- Reserve a weekly outreach block and a handful of gap closure appointment slots, and start with the patients who have three or more open gaps.
