VBC Executive
Value-Based Contract Margin & Clinical Integrity Audit
The Business Problem
A VBC Executive discovers that a musculoskeletal (MSK) value-based contract is underperforming by $3.2M annually. The root cause could be anywhere: clinical variation, supply chain costs, billing patterns, or contract term misalignment. Traditional investigation requires 3-4 months of analyst work across siloed teams.
The integration complexity:
- EHR: Extract ERG severity scores and risk adjustment data for “rising risk” populations
- ERP: Pull actual supply chain costs - orthopedic implants, cardiac stents - reconciled against normalized pricing
- RCM: Ingest 18 months of claims to identify unwarranted billing variation across Commercial, Medicaid, and Medicare Advantage
- Unstructured (100+ docs): Parse payer contracts (PDFs), clinical pathway guidelines (Markdown), and provider attribution documents
The analytical complexity:
- Cross-reference clinical pathway compliance against actual implant utilization
- Identify high-cost implants used that violate payer contract specifications
- Correlate "best-practice" clinical notes with repeat visit rates indicating treatment failures
- Calculate quantified opportunity if care patterns aligned to contracted terms
Why RAG + LangChain fails:
| Requirement | Failure Mode |
|---|---|
| Multi-system joins | Cannot join EHR patient records to ERP supply costs to RCM claims |
| Contract ingestion | Cannot parse 100+ contract PDFs and reason over conflicting payer terms |
| Variance attribution | Cannot trace a $3.2M variance to specific providers, implants, and episodes |
| Audit evidence | Cannot produce audit-ready evidence for CFO and CMO review |
How Zenera Solves It
Zenera's agentic execution
- 1Self-coding EHR integration: Agent analyzes enterprise EHR platform FHIR API documentation, synthesizes extraction logic for ERG severity scores, validates against sample patients
- 2Self-coding ERP integration: Agent connects to an enterprise supply chain ERP platform, maps implant catalog codes to cost centers, reconciles pricing against contract terms
- 3Self-coding RCM integration: Agent ingests claims from an enterprise revenue cycle platform, applies ETG episode grouping logic, identifies billing anomalies
- 4Document corpus reasoning: Agent parses 100+ PDFs using vision models, extracts contractual reimbursement limits, cross-references clinical pathway requirements
- 5Transactional analysis: All data operations execute within LakeFS branches - if any integration fails, the analysis rolls back cleanly
- 6Explainable output: Every finding traces to source systems and documents; CMO can drill into the exact contract clause violated
Time to Insight
12 minutes (vs. 3-4 months manual)