Healthcare organizations process thousands of medical claims per day, determining payment based on complex government codes and their own additional guidelines. In doing so, organizations must balance accuracy with strict response deadlines and the cost of processing each claim. If an organization accidentally overpays for care or pays a duplicate bill, the money comes directly from profits. The sheer volume of this work could translate into a massive loss of premium dollars annually.
Detect Fraudulent and Abusive Billing Patterns with Virtual Examiner®
PCG Software’s Virtual Examiner® allows healthcare organizations to enhance their current claims adjudication system with more than 31 million claims edits per claim. The user-friendly, scaleable software tool monitors an organization’s internal claims process to identify unclean claims and reduce payment for improper or erroneous coding to conserve important premium dollars.
However, Virtual Examiner is more than a claims review system with a focus on code combinations. It is a cost containment program that evaluates the claim not only for fraudulent and abusive billing practices 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 software that focuses 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. Its platform affords flexibility to comply with frequent business and legislative changes.
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’s Vista 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.
Click Here for a screenshot of Virtual Examiner!