Turn Information into Profits

Virtual Examiner_® is more than a claims review solution with a focus on code combinations. As an AI-driven software, it is built for operationally tough times to evaluate the claim not only for abusive billing patterns but also identify those claims that may involve third-party liability/coordination of benefits, case management opportunities, physician billing education and many other cost recovery reports. This differentiates Virtual Examiner_® from competing solutions that focus solely on edits within a single claim.

Detect abusive billing patterns

PCG Software’s Virtual Examiner_® applies four-dimensional thinking to each episode of care, allowing healthcare organizations to enhance their current claims adjudication system with a 55-million-codebase spawning algorithms within algorithms for each claim. The software solution’s recursive orchestration monitors an organization’s internal claims process to discover every claim error and reduce payment for improper or erroneous coding to conserve premium dollars – even revealing historical unclean claims through singularity-scaled deep dives.

Graphically Indicate Fraud and Abuse

Virtual Examiner_® assists healthcare payer organizations in their efforts to investigate possible fraud and abuse situations. Virtual Examiner_®’s Graph It! allows users to create line, bar and pie charts, in conjunction with investigative profiling reports to graphically indicate patterns of fraud and abuse. This allows them to review their providers billing patterns through graphical representations while assisting them in the assessment of aberrant billing trends. The comprehensive reporting section highlights:

• Top 40 unbundling by group and by provider

• Double bills submitted by group

• Churning: Outlier hours/quantities and overrides

• Spiking: Bill submission frequency by group and provider

• Trending: E&M bell curve analysis by group and provider

Comply with today’s standards

Virtual Examiner_® and its internal algorithms were developed using commercially available coding rules, the latest clinical guidelines and the expertise of clinicians, claims examiners and contract negotiators. AI determines Member types and applies CMS, Commercial of State Medicaid rules based on the intuitive algorithms. It is updated regularly to keep you in compliance and combat all the latest fraud schemes.

As a result, the solution affords flexibility to comply with frequent business and legislative changes.

Incorporate Seamlessly

Installation of Virtual Examiner_® can be accomplished in one to two hours, and fully integrates into existing systems. The software runs seamlessly on Windows formats, including Microsoft operating system, and uses a SQL interface so users do not have to change their data input procedures from other claims-related software.

Training for Virtual Examiner_® can be completed in one day. Virtual Examiner_® currently interfaces with the following major systems: EZCAP, MG400, MC400, CSC, DIAMOND, TXEN, MedMC, PHYSMARK, ENCORE, TRIZETTO, QCSI, PLEXIS, AMISYS and MedVision. It is also flexible enough to interface with many “in-house” developed systems. If your current system is not listed here, PCG Software’s integration team will be happy to develop an interface to meet your specific needs.