PCG Software
Maximizing Financial Recoveries through Virtual Examiner®

As fraud, abuse and waste continue to roil the current healthcare landscape, health plan CIOs are seeking more secure and enhanced platforms to adjudicate the claims coming in from healthcare providers. While there have been a number of advancements in health IT systems, many platforms still lack the ability to effectively monitor the complicated and evolving rules and regulations of the healthcare industry. To address the need for more automated methods of reducing the cost of healthcare, PCG Software works with both payers and providers to streamline cost containment, maximize financial recoveries and significantly reduce the incidence of fraud, abuse and waste. “We ensure our clients’ network is not only compliant, but is structured in such a way as to maximize profitability,” says Michael Lubao, CEO, PCG Software.

Since its establishment, nearly thirty years ago, PCG Software has focused on providing a comprehensive suite of software solutions to the healthcare industry. “For the payers and providers, our healthcare software tools automate cost containment through effective claims adjudication and code review,” remarks Lubao. The tools and solutions help health plans, TPAs, and other payers work with the most accurate claims, administrative and physician information available from their provider networks.

To monitor fraudulent and abusive billing patterns and maximize the financial recoveries, PCG offers Virtual Examiner® (VE), the company’s flagship software product. The engine monitors the internal claims process of an organization to trend provider data, analyze abusive billing patterns, and focus on the appropriate edits within patient claims. “Currently our Virtual Examiner® can enhance a customer’s claims adjudication system with 32 million edits per claim,” clarifies Lubao. PCG’s workflow management application, Virtual Reporter®, improves the workflow of the three main areas of the Virtual Examiner® engine—cost containment, financial recoveries and fraud/abuse detection.Virtual AuthTech®, another interface of VE, is similar to an online book for Centers for Medicare and Medicaid Services (CMS) rules and is an interactive diagnosis and procedure code researcher, unbundler, and reviewer.

Virtual Credentialer™, performs the standard credentialing process for physicians, ensuring that the doctors working in the healthcare provider network are licensed and legal.

By providing these solutions, the company aims to educate their customers and their networks on the negative impact of fraud, abuse and waste, and help them better compete in today’s healthcare marketplace. In one instance, “We implemented Virtual Examiner® for St. Joseph’s Medical Resources, an organization that manages Independent Physician Associations (IPAs) and conducts billing and utilization management for physician practices. Our solution increased their profitability by managing all of the complex claims within their system.” Through the use of PCG’s software, the organization is now seeing enhanced administrative flexibility and functionality across the board for managing its 80,000 patients.

Our software tools automate cost containment through effective claims adjudication and code review for healthcare providers and payers

In addition to the VE offering, PCG Software collaborated with HCIM, a technology solutions vendor. The organizations partnered to develop SymKey® Virtual Auto-Post™, an auto-adjudication system that is integrated with VE. In addition, the company has developed Virtual Real-Time engine (VERT), which allows other healthcare IT vendors to provide the same level of fraud, abuse and wasted detection, as well as claims adjudication support to their own customers.

The company focuses exclusively on the healthcare landscape, and its diverse set of solutions are resolving the administrative and operational challenges of its stakeholders. “We provide a live analysis in the fraud and abuse operations and provide an extensive knowledge base for our clients on each consultation,” exclaims Lubao. In the year ahead, PCG plans to provide better coding support for the management of ICD-10 codes and increase the number of edits in the VE system to 40 million.