Your analytics tell you who needs attention. Your care management program tracks the work. The gap is getting it done — at the scale of your attributed panel, across a full performance year, without adding coordinator headcount you don’t have budget for.
Request a DemoMSSP ACOs and risk-bearing MSOs operate with a clear financial equation: shared savings depend on keeping total cost of care below benchmark, which depends on care management execution quality. The data to identify the work is usually adequate. The execution infrastructure to complete it at panel scale is not.
Industry data consistently shows that manual outreach reaches fewer than 30% of eligible patients within the 24–48 hour window. The missed patients are the ones most likely to return to the ED — and most likely to drive readmission costs against your TCOC benchmark.
ZynGap identifies the gaps. Closing them before the performance year ends requires outreach, scheduling, visit completion, and documentation alignment that coordinator capacity cannot sustain at full-panel scale. Most ACOs leave RAF score on the table at year-end.
Care coordinators carry the full execution load of value-based care programs. The patient-to-coordinator ratio means some work doesn’t get done — not because the team isn’t working, but because the volume requires an execution layer, not more headcount.
CCM billing represents significant unrealized revenue for ACOs with chronic disease panels. Capturing it requires consistent monthly patient contact and billing-ready documentation that most coordinator teams cannot sustain at scale.
Zynix AI carries the execution volume that care management programs generate but coordinator teams cannot sustain. It operates at the intersection of your intelligence layer and your patient population — completing the work the analytics identify.
Every patient on the follow-up list gets contacted. Every CCM-eligible patient gets a monthly touchpoint. Every HCC gap gets an outreach trigger. The care team handles clinical escalations — Zynix AI handles the volume.
The HCC + Quality Gap Closure Sprint coordinates outreach, scheduling, and documentation on a performance-year timeline — prioritizing by RAF impact and closure window. Programs don’t stall in Q4 when coordinator bandwidth is already stretched.
Predictive signals on rising-risk and readmission-risk patients trigger outreach before the clinical event. Barrier capture routes resolution through the same interaction. The cost that doesn’t happen is the shared savings that does.
Every non-emergent ED visit by an attributed patient is a direct hit to TCOC. Consistent after-hours access — clinical triage, self-care guidance, next-day scheduling — keeps routine care needs from defaulting to the ED.
Use Cases
The 48-hour post-discharge window is where ACO performance is won or lost. Full workflow from ADT trigger through 30-day close, including TCM billing capture.
View use case →RAF scores are documentation scores. End-to-end gap closure: prioritized by RAF impact, executed before year-end performance close.
View use case →Prediction without action is just an earlier warning about a cost you didn't prevent. How ZynPredict signals translate into structured proactive outreach.
View use case →The ACO's after-hours answer rate is a shared savings metric hiding in the phone system. The connection between access and TCOC, operationalized.
View use case →CCM billing revenue is sitting in your patient panel. The consistent monthly contact and documentation workflow that most ACO coordinator teams cannot sustain manually.
View use case →Platform
Post-Discharge TCM Care Plan, HCC + Quality Gap Closure Sprint, High-Utilizer ED Diversion Plan, Medication Safety and Adherence Plan. Multi-agent programs built around ACO performance-year priorities.
Transitions of Care Agent, Chronic and Longitudinal Care Management Agent, Preventive and Quality Activation Agents, SDoH Determination Agent. The execution layer your care management program identifies the work for.
HCC and quality gap identification prioritized by RAF impact and closure timing. Actionable worklists for coordinators, not raw gap data that has to be triaged before it can be acted on.
24/7 after-hours triage for your attributed population. Clinical triage logic, 15+ languages, ED diversion built in. Every non-emergent call that stays out of the ED is a TCOC win.
ACOs achieving benchmark shared savings consistently show higher care management completion rates, post-discharge contact rates, and HCC closure rates than those that miss targets.
The performance gap between top and bottom ACO quartiles is not explained by panel complexity alone. Execution quality is the differentiating factor.
Manual post-discharge outreach reaches fewer than 30% of eligible patients within the 24-48 hour contact window, the window where readmission risk is highest.
For MSSP ACOs, every missed post-discharge contact in this window represents both a care quality gap and a TCOC exposure.
ACOs relying on manual outreach capture a significantly lower share of eligible TCM reimbursement than those using systematic outreach workflows.
Reaching more patients produces more complete billing documentation. Contact rate and TCM billing capture move together.
Coordinator-to-patient ratios in most MSSP ACOs make full-panel chronic care management execution impossible without a systematic outreach infrastructure.
The CCM billing gap in most ACO panels is a contact rate problem, not a patient eligibility problem.
Platform
Post-Discharge TCM Care Plan, HCC + Quality Gap Closure Sprint, High-Utilizer ED Diversion Plan, Medication Safety and Adherence Plan. Multi-agent programs built around ACO performance-year priorities.
Transitions of Care Agent, Chronic and Longitudinal Care Management Agent, Preventive and Quality Activation Agents, SDoH Determination Agent. The execution layer your care management program identifies the work for.
HCC and quality gap identification prioritized by RAF impact and closure timing. Actionable worklists for coordinators, not raw gap data that has to be triaged before it can be acted on.
24/7 after-hours triage for your attributed population. Clinical triage logic, 15+ languages, ED diversion built in. Every non-emergent call that stays out of the ED is a TCOC win.
Use Cases
The 48-hour post-discharge window is where ACO performance is won or lost. Full workflow from ADT trigger through 30-day close, including TCM billing capture.
View use case →RAF scores are documentation scores. End-to-end gap closure: prioritized by RAF impact, executed before year-end performance close.
View use case →Prediction without action is just an earlier warning about a cost you didn't prevent. How ZynPredict signals translate into structured proactive outreach.
View use case →The ACO's after-hours answer rate is a shared savings metric hiding in the phone system. The connection between access and TCOC, operationalized.
View use case →CCM billing revenue is sitting in your patient panel. The consistent monthly contact and documentation workflow that most ACO coordinator teams cannot sustain manually.
View use case →ACOs achieving benchmark shared savings consistently show higher care management completion rates, post-discharge contact rates, and HCC closure rates than those that miss targets.
The performance gap between top and bottom ACO quartiles is not explained by panel complexity alone. Execution quality is the differentiating factor.
Manual post-discharge outreach reaches fewer than 30% of eligible patients within the 24-48 hour contact window, the window where readmission risk is highest.
For MSSP ACOs, every missed post-discharge contact in this window represents both a care quality gap and a TCOC exposure.
ACOs relying on manual outreach capture a significantly lower share of eligible TCM reimbursement than those using systematic outreach workflows.
Reaching more patients produces more complete billing documentation. Contact rate and TCM billing capture move together.
Coordinator-to-patient ratios in most MSSP ACOs make full-panel chronic care management execution impossible without a systematic outreach infrastructure.
The CCM billing gap in most ACO panels is a contact rate problem, not a patient eligibility problem.