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.