#1 AI Medical Claims Auditing Software for Health Plans, MSOs, and IPAs

Virtual Examiner®

  • 160+ payers saved billions over 30 years
  • 100% claims auditing potential
  • Full Episode of Care Auditing every night
  • Fraud, Waste, and Abuse modules
  • 68 million edits: NCCI, CMS, Medicaid, Customized Edits
  • 99% of clients see ROI in 90 days or less
FREE 3-year claims Audit

Imagine

AI Claims Auditing for Payers

What is Virtual Examiner®

AI Claims Editor with Reason Codes Serves as Instructor to Employees

Imagine saving millions every year, cleaner encounter data, and happier claims examiners with the usage of Virtual Examiner®. Every night it will audit the days claims, quarantine those claims based on a 3-year full episode of care audit, and then tell you every possible reason to deny, reduce, or pend for contractual review, all based on CMS and AMA guidelines. Virtual Examiner® will not only tell you why a claim should be denied, the CMS definitions and coding suggestions,  as well as a layman’s term of what the information provided means. It’s not just a Claims Editor or Claims Auditor, it’s a guiding tool to optimizing your Claims Department process and helpful in onboarding new employees.

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Cost Containment

  • Provider Overpayment Trends
  • Coding Related Overpayments
  • Reduced Hiring Needs
  • Reduced Burnout
  • Educational Tool
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Operational Efficiency

  • Runs millions of claims per night
  • 400+ Reasons to Pend or Deny
  • Full 3-year Episode of Care Review
  • Know exactly what claims to review
  • Improve Case Management
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Compliance

  • HEDIS Improvement
  • Improper DX Usage
  • Improper POS Usage
  • Improper Sex Classifications
  • Fraud, Waste, and Abuse

Modules and Benefits of Virtual Examiner®

Virtual Reporter® - VR

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Increased Efficiency of Claims Department

Our AI Engine, Virtual Examiner® has a reporting module called Virtual Reporter®. Every night Virtual Reporter® will run all of your unpaid claims against the latest CMS, AMA, and State Medicaid guidelines and your pre-set exclusions. When your team comes into work the next day, they have reports of only the claims that have one of 400 possible reason codes for denial. Your team can then review those claims and find the reasons for each suggested denial or pending, and not only make that decision but also learn from the reason codes for faster future reviews and decision making.

  • Runs Millions of Claims per Night
  • Easy to Learn, Easy to Use
  • 3 Sweeps of Claims, 3-year Analysis
  • Filter by Line of Business
  • Customized Contract Exclusions Parameters
  • Assign multiple LOBs to each auditor
  • Specific Code & Modifier Trend Report

Virtual AuthTech® - VA

The Clear Claim Connection

The Perfect Claims Audit Tool

With your new Virtual AuthTech® module, your Medical Management and Authorizations teams will be equipped to review complex authorizations and run mock adjudications to avoid erroneously approving claims that are not medically necessary, fall under a CCI edit, or hundreds of other reasons to which Virtual AuthTech® within it’s Machine Learning AI Knowledge base will advise you on next steps.

  • Research Medical Codes
  • Run Mock Adjudications
  • Run Mock Authorizations
  • ICD, LCD, POS, GPCI, Modifiers, NDC & more
  • Contract Negotiation Tool
  • Updated Quarterly unlike Coding Books
  • Coding Rule AI Algorithms
  • Profession v Facility Findings
  • Financial Reviews of Claims/Auth
FREE 3-year claims Audit
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SymKey® Virtual Auto-Posting

Claims Automation AI

PCG and your IT Department will work hand in hand to identify the possibility of auto-adjudication with Virtual Examiner® and your current in-house or commercial recognized claims software already in place. Integrations can lead to auto-posting capabilities, expedited speed in AI claims tasks, AI generated tracking of retro-rate reconciliation, AI generated eligibility review, AI generated co-pay / co-insurance correction, and can be installed in a single day.

SymKey is a registered trademark owned by HealthCare Information Management, Inc (HCIM) and integrates with Virtual Examiner® To get a listing of integrated systems book a FREE consult with PCG.

FREE Comprehensive AI Medical Claims Audit

Guaranteed ROI and Data on Future Cost Containment

In less than 10 days, PCG’s Claims Expert and Virtual Examiner® will conduct a full 3-year claims analysis identifying codes and processes that produced overpayments and claims that should have never been paid in the first place. Your Audit will show you how to reduce risk, what to recover first, and what to immediately address with your teams. Lastly, we go over how we make our Claims Editor, Auditor, Authorizations Tool, and Support, provide you an ROI in 90 days or less from a signed contract. This full report is shown to you, your claims team members, and decision makers at your headquarters. This entire auditing process is valued at $50,000 but we're willing to do this for FREE if both parties agree to the audit.

FREE 3-year claims Audit

Knowledge is Power

What does your data tell you?

Virtual Examiner is your Data Analyst, Compliance Officer, and CMS and AMA Expert,  all rolled into one.


  • Top 40 unbundling by group
  • Top 40 unbundling by provider
  • Double Billing
  • Improper and Fraudulent usage of Modifiers
  • Improper or Abusive Medication Prescribing
  • Place of Service errors
  • Billing submission frequency, aka "Spiking"
  • E&M graph provider and group error trends.
  • Every code, every scenario, its there for you!


And about a million other things we'll get into during our FREE Consult

Virtual Examiner Client Support Programs

Virtual Examiner® Implementation

At PCG, we believe in Clients first. That’s why we fly out to your headquarters, train your claims and medical management teams, your provider relations, and your fraud, waste, and abuse teams. While we’re training you and your team, we’re also training on live claims that require editing and denials pre-check runs and paid claims that require review and recovery.  PCG and Virtual Examiner save you money from Day 1.

Virtual Examiner® Support Team

Once we get your team live, you have the full support from our IT Team, our Certified Professional Coders, Nurses on Staff, and even our Executives. We are a hands on, results and support driven company.

PCG Newsletter

All Virtual Examiner® (VE) and VEWS clients of PCG get our quarterly Newsletter and regular updates on the latest Code Edits, Lawsuits, and Tactics for higher profitability. The PCG Newsletter is also located within Virtual AuthTech® and can be downloaded at any time.

Provider Relations: Operation Clean Claims

PCG Software’s Virtual AuthTech® has a twin sister that we call iVECoder ® that can be used by clinics to submit cleaner claims. Our CSO would happily walk your provider relations through your provider letters, outreach and possibly iVECoder adaption.

FREE 3-year claims Audit

FAQs about Virtual Examiner®

Asked and Answered Common Questions about Virtual Examiner®

  • What claims and eligibility softwares does Virtual Examiner integrate with?

    We integrate with most commercially and home-grown claims adjudication softwares. During our initial consultation we'll find what softwares you use, the needs you'll have and can even help provide guidance on the most cost effective and appropriate softwares you could consider now or in the future.

  • How long is the full implementation process?

    The first implementation takes 4-5 days, and then PCG staff will follow up with Fraud, Waste, and Abuse in the second training about 30-90 days after. It’s necessary to ensure that claims and medical management first understand the processes and the software.

  • How do I explain an increase in denials to my providers?

    We help your Provider Relations understand how to submit written letters notifying clinics of the changes that they will see in the future, and possible recoveries they may have to endure, as well as the reasoning behind it. PCG has done this for 30 plus years, and our Chief Strategy Office would be happy to contact providers with our Operation Clean Claims Act.

  • What is needed for my 3-year Audit?

    PCG requires a formal NDA and BAA in place, and then we'll send the details on the specific parameters of the data set we need. Most Audits take 10 days or less. 


    Following the complete audit, we provide you with a full review of Virtual Examiner, our findings, and a full pricing proposal of our Software solutions; Virtual Examiner®, Virtual AuthTech®, and Virtual Reporter®. 

  • What do Audits cost?

    Audits have a 3-tiered pricing structure ranging from $20k - $75k per audit. If your payer organization chooses to install and run Virtual Examiner, a portion of the Audit will then be applied to your 1st-year fees for our software and support. 

FREE 3-year claims Audit

Case Studies of Success

Monarch Health Systems

Customizable work queues saves them $160,000 or more every month!

Read full story

Naperville Healthcare Associates

Physician-hospital organization saw a 56 percent savings increase on fee-for-service claims. Read full story

Tuality Health Alliance

Physician-hospital community organization with 300+ providers reduced 10% of overpaid claims in year 1. Read full story

Physicians Integrated Medical Group

Within 30 days of implementing Virtual Examiner, PIMG had already saved $30,000 in overpaid claims during their audit. Ready full story