PCG Software, Inc is an American company devoted to strengthening the American workforce and upholding our commitment to never using internationally outsourced labor. All of our products are designed and engineered in the United States.

Virtual Examiner®

Virtual Examiner®, PCG Software’s flagship product, monitors the internal claims process of an organization to trend provider data for fraudulent and abusive billing patterns, and maximizes financial recoveries.

 

Detect abusive billing patterns

PCG Software’s Virtual Examiner® allows healthcare organizations to enhance their current claims adjudication system with more than 31 million edits per claim. The software solution monitors an organization’s internal claims process to identify unclean claims and reduce payment for improper or erroneous coding to conserve premium dollars.

Contain costs

Virtual Examiner® is more than a claims review solution with a focus on code combinations. It is a cost containment solution that evaluates the claim not only for abusive billing patterns but also identifies 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.

Process up to 233,000 claims per hour

Virtual Examiner® exponentially increases efficiencies over reviewing claims manually, reducing the need for healthcare organizations to maintain massive claims and administrative staffs.

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.

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.