HCC Gap Closure and RAF Score Optimization

An MSSP ACO's shared savings calculation depends on the accuracy of its risk score relative to its benchmark. Patients with complex chronic disease profiles — multiple comorbidities, documented histories of heart failure, diabetes with complications, COPD, chronic kidney disease — carry significant RAF weight. When those conditions are coded in the current data submission, the risk score reflects the true population complexity. When they are not, the benchmark is set against a population profile that does not accurately represent the patients being managed.

The documentation is there. In most cases, the conditions have been active and treated throughout the year. The problem is that current-year coding requires a face-to-face encounter in which the condition is reviewed, documented as active, and appropriately coded in the visit note. Patients who are not seen in a given year — or whose visit notes do not include explicit documentation of the chronic condition — do not contribute to current-year RAF. Across hundreds of patients with complex co-morbidity profiles, the aggregate RAF impact is not marginal.

Closing the gap before year-end requires two parallel workflows: for patients with upcoming appointments, pre-visit documentation briefs need to reach the care team in time for the condition to be reviewed and coded. For patients without upcoming appointments, outreach is needed to schedule a visit before the year-end coding window closes. Both workflows require infrastructure that runs at population scale.

ZynGap surfaces HCC and quality gaps for every patient in the attributed population, ranked by RAF dollar impact and closure timing. For patients with upcoming appointments, pre-visit documentation briefs are generated and delivered to the care team before the visit — so the chronic condition review and documentation happens at the encounter rather than being missed.

For patients without upcoming appointments, the Preventive and Quality Activation Agents run outreach — identifying barriers to scheduling, booking the visit through ZynSchedule, and following up with patients who agreed to schedule but have not confirmed. ZynReminder handles the follow-up cadence so coordinators do not need to manage individual patient tracking across hundreds of open items.

The platform tracks completion at every step. For an ACO executive team tracking shared savings performance against the year-end target, this visibility allows mid-year course correction rather than a post-performance-year reconciliation of what was missed.