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Overwhelmed by Value-Based Contracting Compliance? RPA Can Help Lighten the Load

Authored by: Jon Swisher & Steve Hunt

Confusion, lack of clarity, and uncertainty surrounding value-based contracting are often overwhelming for medical practices. Demonstrating compliance requires a significant amount of work, as each payer has its own set of rules and requirements, leaving many practices to ask:  

  • What are we being measured on, and what measurements trigger financial gains or penalties? 
  • What are the data collection and submission requirements associated with the programs?  
  • Do we need to add special codes to our claims, or submit clinical data from our EHR to payers? 
  • What is the most efficient way to track progress toward the goal?  

As you navigate this complexity, an issue that often arises is not having enough staff to keep up with compliance-related tasks. Robotic process engineering (RPA) can be a significant part of solving that challenge.  

How RPA helps with contract compliance  

With value-based contracting, it’s common for each payer to have its own portal to gather data about which populations are measured and tracked.  

Completing this process manually requires a decent amount of staff time. However, RPA could log into the required portals, pull data related to a program, and put it into a suitable format for your provider. Ideally, it could also compare the payer data against the information in your practice system. 

This capability would help you stay on track with program compliance while holding payers accountable and ensuring you receive credit for all services delivered within a specific program. 

Additionally, as you compare data between the payer’s system and your own, RPA could proactively help you identify patients you’re measured against but haven’t seen in your practice. With this information, you could proactively reach out to and support these patients with care. An easy example is preventative care, such as annual wellness exams. Offering to provide these services increases the likelihood of their use and improves compliance with contractual obligations. 

How does RPA complete tasks?  

If you haven’t used RPA in your practice, you might have questions about how it works. A bot is trained similarly to how you would train a person to complete a task that follows a set process, where no decision is required. For example, bot software can record clicks, check boxes, and perform other typing-associated tasks. An action framework directs the bot on how to maneuver through specific steps. 

 

When a human decision is required, the bot stops, but that decision can be part of a larger process or workflow. A bot could compile a data set, present it to a user, await a decision, and then take one of two paths based on the user’s decision. 

 

If you’re unsure if a bot would be helpful, ask yourself, “Could we hire someone brand new, provide them with a process flow or decision matrix document, and point them to a pile of work?” If the answer is yes, it’s ripe for RPA.  

 

However, to be clear, the goal is never to take away human tasks but instead to offload the repetitive nature of certain tasks so that teams are free to complete higher-level work. 

Finding a starting point with value-based contracts and compliance  

The first step in value-based contracting is understanding what’s required and how to use programs to support your practice. Once you understand these points, you can decide if RPA could help lighten the staff workload. 

A great starting point is conducting a cost-benefit analysis, examining the necessary processes, the cost of RPA, and the potential savings. And if you need help with that, reach out; we can help.  

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