AI Revolutionizes Healthcare Cost Containment: PCG Software Leads the Way

In the world of healthcare, artificial intelligence (AI) has emerged as a game-changer in reducing fraud, and Las Vegas-based PCG Software is at the forefront of this revolution. Let's delve into how their cutting-edge technology began reshaping healthcare claims back in 1995 and how articles written in the early 2010s by PCG still hold true today along with updated statistics. 

Did you that AI was being used in 1995?

In a world where AI is now a household term, it's worth revisiting how PCG Software was pioneering AI in 1995 through Machine Learning. The visionary CEO, Michael Lubao, laid the foundation for AI-powered solutions that are now addressing one of healthcare's most pressing challenges - fraud reduction.

Tackling a Persistent Problem

Despite significant progress in healthcare legislation, issues like accurate medical billing and coding persist. One critical aspect is the correct use of modifiers to prevent claim denials by insurance payers. As the healthcare industry shifts from fee-for-service to value-based care models, cost containment is paramount. The National Health Care Anti-Fraud Association (NHCAA) reports that healthcare organizations lost a staggering $60 billion annually to fraud and abuse cases in 2018, which now amounts to a staggering $300 billion. 

The PCG Software Solution

To combat these financial losses and reduce healthcare costs, PCG Software offers a comprehensive suite of software tools. These tools automate cost containment by streamlining claims adjudication, and code review, and offering administrative flexibility. Their impact is being felt by national and regional health insurance plans, independent physician associations, and third-party administrators.

Since this article, VE has added Virtual AuthTech ® which is an AI platform for researching codes and running mock adjudications for Medical Management and used in auditing by compliance and provider relations departments for PCG’s payor clients. 

Cost of Medical Denials 2017 vs 2023

During 2018, nine percent (9%) of all 3 trillion claims were denied. the initial writing of this article, administrative fees for denials for providers was $25 per appeal or PDR. 

In  2022, 20% of claims are denied, and with 59% of payers upholding denials a second appeal is not financially worth it to providers. Why…

Every time a provider submits an appeal it costs them $40 in administrative time and effort alone. If your follow-up visit of 99213 is only worth $50 - $250, then a $40 fee for one appeal makes sense, but for two appeals, that’s not cost-effective considering you have hundreds of claims to process every day. 

Additionally, PCG has created iVECoder ® which is VA but for providers. It gives them payer knowledge on how to audit claims before claims submission reducing denials rates, speeding up collections, and avoiding the $40 administrative fees associated with denials and PDRs.

A Brief History of PCG Software

PCG Software's journey dates back to 1995 when President Clinton launched Operation Restore Trust to combat fraud, waste, and abuse in healthcare. PCG Software began its mission, initially serving a few clients and expanding to a hundred across Puerto Rico. Their expertise in coding edits and focus on insurance payers set the stage for their innovative solutions.

Automation and AI in Fraud Reduction

Fraud and abuse cases in healthcare continue to rise, accounting for 3% of all US expenditures, exceeding $300 billion in 2023. PCG Software's flagship product, Virtual Examiner®, is designed to identify fraudulent billing patterns, maximizing financial recoveries. They've also introduced Virtual AuthTech, an interactive diagnosis and procedure code researcher, to enhance authorization and claims accuracy. The IVECoder tool ensures clean and accurate claims before submission, with regular updates for compliance.

Differentiation and Client Success

PCG Software stands out by prioritizing customer satisfaction. A recent success story involved correcting a billing error, saving a patient $1,400, and providing accurate coding. Such outcomes showcase their commitment to delivering efficient solutions that benefit both providers and patients.

Long-Term Mission

PCG Software's mission centers on simplifying the billing process for patients and improving operational efficiency for payer organizations. By identifying fraud patterns and assisting providers in billing accuracy, they aim to curtail escalating healthcare costs.

In conclusion, PCG Software is a trailblazer in harnessing AI to reduce healthcare fraud. With their suite of innovative tools, they're reshaping the industry and leading the charge toward a more efficient and cost-effective healthcare system.

"PCG understands that healthcare is all about providing care and guiding patients toward a hassle-free billing process is what ultimately leads to a smoother operation."