risk-bearing Organizations, VBC, Medicare Advantage

Protect shared savings where it’s won — at the transition.

The shared-savings opportunity is largest at the transition: when diagnoses are richest, interventions are most actionable, and documentation most often falls through the cracks. Cascala gives clinical and care-management teams the infrastructure to act before a readmission happens, before a coding gap closes, and before the next follow-up or care-management opportunity is missed.

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Post-discharge opportunity capture

HCC recapture

Network-wide visibility

Built for CMS V28

How Cascala helps

Population-level visibility, with a documented record for every transition.

Cascala reaches the care team while the TCM window is open, surfaces suspected HCCs with source-cited evidence, and shows the whole attributed population — so savings get protected before they leak.

Capture the TCM window

ADT-informed alerts and consolidated records reach the care team while the window is still open — so eligible follow-up actually gets done, and billed.
Recapture HCCs at the richest moment

Suspected conditions and care gaps surface before the encounter closes, with source-cited evidence behind every extraction — supporting clean, defensible documentation under CMS V28.
See the whole attributed population

Network-wide visibility across attributed lives and your entire post-acute network — readmission risk, utilization, and follow-up status in one view.
A record built for shared savings & stars

A documented, auditable record across every setting — the evidence base for shared-savings reconciliation and star ratings.

Proof, not promises

Outcomes from real deployments

71%

faster ADT-to-record delivery at Palm Beach ACO — the market’s AI-native ACO proof point.

87.5%

AI recommendation accuracy.

<10 min

average time to a referral recommendation.

Population level visibility.

Replaces a black-box 30 days after discharge — infrequent handoffs, PCPs who miss the TCM window, and savings that leak into readmissions and ED use.

Readmission rate

12%

-2.1% vs. prior year

Total patients

2,688

+6.6% vs. prior year

Total admissions

2,748

+6.0% vs. prior year

High risk patients

444

-21% vs. prior year

Length of stay

5.9 days

-9.3% vs. prior year

Care-gap report in

Now: The health plan sends the care-gap report; outreach schedules; the patient is scheduled in the EHR 48+ hours prior.

Cascala starts the moment the visit is scheduled.

Chart prep

Chart Prep + Cross-Facility Patient 360°: retrieves records and surfaces the suspected HCCs and HEDIS gap evidence before the encounter — each with Verified & Visible Sources — and loads the problem list and evidence into the EHR.

The visit

CASS: the provider reviews the problem list and evidence before the visit, closes the gaps, and publishes the note — capturing conditions at the richest moment, under CMS V28.

Final review & claim

Comparison Report: flags discrepancies between the note and the evidence; the coder resolves them; the claim goes out clean — backed by a documented, auditable record for shared-savings reconciliation and star ratings.

The workflow

From care-gap report to a clean, defensible claim.

Cascala prepares the evidence, supports the visit, and checks the note before submission — so gaps close, HCCs are captured at the richest moment, and the documentation stands up to audit.

Care-gap report in
Chart prep
The visit
Final review & claim

Records prepared retrieved and ready for attributed patients. Evidence surfaced HCC and HEDIS gap evidence, cited, before the visit. Quality assured a documented, audit-defensible record behind every claim.

risk-bearing Organizations, VBC, Medicare Advantage

Protect shared savings where it’s won — at the transition.

How Cascala helps

Population-level visibility, with a documented record for every transition.

Capture the TCM window

Recapture HCCs at the richest moment

See the whole attributed population

A record built for shared savings & stars