Ask a practice manager in early December how the quality year is going and the answer is usually a sigh. The payer gap list arrived in October with 600 open gaps, the schedule is full through the holidays, half the patients on the list do not answer the phone, and the incentive check depends on numbers that will freeze on December 31. This happens every year, and every year the practices that did well started in September.
2026 adds a reason to start even earlier. Medicaid expansion adults face six-month renewals and work requirements beginning at the end of December, Marketplace patients will shop plans in November against double-digit premium increases, and a patient who leaves your panel or loses coverage in January takes an open gap with them. The gap still counts against you for the 2026 measurement year, and you lose the chance to close it. Whatever you can close before the churn, close.
Key takeaways
- A third or more of the gaps on a payer's list are not gaps. Reconcile against the chart before anyone picks up a phone.
- Rank the truly open gaps by contract dollars, by how close the patient is to closing, and by the patient's risk of losing coverage in January.
- Build schedule capacity before outreach generates appointments, and combine every gap a patient has into one visit.
- A closed gap the payer does not know about is an open gap. Supplemental data submission is part of the plan, not an afterthought.
Which gaps pay, and which matter
Not every measure carries the same weight. Before outreach starts, list your value-based contracts and the measures each one pays on, then sort. In most primary care practices the list looks something like this:
| Measure (HEDIS abbreviation) | What closes it | Where the evidence usually lives |
|---|---|---|
| Controlling High Blood Pressure (CBP) | A blood pressure reading under the threshold at the last visit of the year | Vitals in the EHR; a late-year visit can replace an earlier high reading |
| Glycemic Status Assessment for Patients With Diabetes (GSD) | Most recent A1c (or glucose management indicator) under the threshold | Lab result, in the EHR or at the lab |
| Eye Exam for Patients With Diabetes (EED) | Retinal exam in the year (or prior year if negative) | Often outside your records; needs the eye doctor's report |
| Colorectal Cancer Screening (COL-E) | Colonoscopy, FIT, FIT-DNA or other test within the measure's interval, ages 45 to 75 | GI report or lab result; historical colonoscopies often undocumented |
| Breast Cancer Screening (BCS-E) | Mammogram within the interval | Imaging report from an outside facility |
| Cervical Cancer Screening (CCS) | Cytology or HPV test within the interval | Lab result; hysterectomy exclusions frequently missing |
| Medicare Annual Wellness Visit (G0438, G0439) | The visit itself, once per twelve months | Your schedule |
Step one: reconcile the payer list with the chart
A third or more of the gaps on a payer's list are not gaps. The colonoscopy was done in 2023 at a hospital whose report never reached the payer. The patient had a hysterectomy and is excluded from cervical screening. The A1c was drawn at a lab the payer does not receive data from. Before you call a single patient, have a medical assistant or care coordinator work the list against the chart and sort every line into three piles: truly open, closed but undocumented to the payer, and excluded. The second pile is closed with a supplemental data submission or a chart upload, not a visit. Every payer has a process for this; find out the format and the deadline, which is often in January or February for the prior year.
Step two: prioritize
Rank the truly open gaps by three things: dollars attached (which contract, which measure weight), how close the patient is to the threshold (a patient one A1c draw from closing beats one who needs a colonoscopy referral and a prep), and whether the patient is likely to lose coverage in January (Medicaid expansion adults with renewals due, Marketplace patients). Work the top of the list first. A practice with 600 gaps and eleven weeks cannot close all of them; it can close the two hundred that matter most.
A worked example. A three-provider practice receives a Medicare Advantage gap list of 600 lines in early September. After reconciliation: 190 are closed but undocumented (a supplemental file closes them), 45 are exclusions (documented and submitted), and 365 are truly open. Of the 365, about 140 are blood pressure and A1c gaps that a nurse visit or a lab draw can close, 110 are screenings that need an outside appointment, and 115 are annual wellness visits. The contract pays most on CBP, GSD and COL-E. The practice puts the 140 quick closures first, books wellness visits that also capture a blood pressure and a lab order second, and sends mammogram and colonoscopy referrals with a follow-up call in the same week. By the second week of December it has closed about 260 of the 365, and it has done it without a single call to a patient who had already had the test.
Step three: build the schedule before the calls
Outreach that generates appointments the schedule cannot absorb produces no-shows and frustration. Block gap-closure capacity now: a half day a week per provider in October and November for wellness visits and chronic disease follow-ups, nurse visits for blood pressure rechecks and A1c draws, and standing orders so that a medical assistant can draw the A1c or schedule the mammogram without a provider visit where your policies allow. Combine gaps per patient: one visit that captures the blood pressure, the A1c, the wellness visit and the mammogram referral is worth four calls.
Step four: outreach in waves
- September: portal message and text to every patient with an open high-priority gap, offering a specific type of appointment. Response rates are higher than calls and the cost is close to nothing.
- October: phone calls to non-responders, scripted, by a medical assistant or care coordinator, with the ability to schedule on the call. Include the address-confirmation question for Medicaid patients.
- November: second call and a letter for the remaining high-priority patients; at every in-person visit, the rooming staff check the gap list and close what can be closed in the room.
- Early December: final push on patients with appointments who have not come, and on undocumented closures that need chart retrieval before the payer's supplemental data deadline.
Step five: get the data to the payer
A closed gap the payer does not know about is an open gap. Submit supplemental data (a CCDA extract, a spreadsheet in the payer's format, or a chart upload through the portal, depending on the plan) on the schedule the payer requires, and confirm receipt. In January, request the updated gap list and compare it with what you submitted. The differences are your appeal list, and most payers accept documentation for the prior year for several weeks. Keep the confirmation emails; when an incentive payment arrives short in the spring, they are the evidence.
Mistakes we see
Starting in November. Calling patients before confirming the schedule has room. Working the payer list without reconciling it, so staff call patients about colonoscopies they had. Treating the annual wellness visit as separate from gap closure when it is the best vehicle for it. Forgetting the exclusions, which count as much as closures. Not asking the Medicaid patient to update their address while you have them on the phone. And measuring effort (calls made) instead of results (gaps closed and accepted by the payer), so nobody knows in February whether the fall was worth it.
Questions we hear
We do not have a care coordinator. Who does this?
In small practices it is a medical assistant with four protected hours a week and a good spreadsheet. The reconciliation step is the largest time investment and it is also the one that most reduces wasted calls. Our closing gaps in care service does the reconciliation, prioritization and outreach for practices that need the capacity.
Does this help with PCMH?
Directly. Population outreach on quality measures is what the performance measurement and quality improvement concept is about, and the reconciliation process is documentable evidence. Our PCMH annual review team can show you how to present it.
Is it too late to start if we read this in October?
No. Skip the September wave, reconcile the list in one week, and start calls in the second week. Fewer gaps will close than if you had started now, but far more than if you wait for the December sigh.
What to do this week
- List your value-based contracts and the measures each pays on, with the weight or dollar value beside each.
- Request the current gap list from every payer that produces one, and the supplemental data format and deadline at the same time.
- Assign the reconciliation to a named person with protected hours and a target date of September 18.
- Block the October and November gap-closure capacity on every provider's schedule now.
- Draft the September portal message and text, one per gap type, and send the first wave by September 14.
