Virtual Examiner®
#1 AI Medical Claims Auditing Software for Payer Organizations
Identify improper payments before they're paid and deliver measurable ROI on every accepted determination.
Purpose Built for Healthcare Payer Organizations
Every healthcare organization has different reimbursement models, compliance requirements, and financial risks. Select your organization to see how Virtual Examiner delivers measurable results.
🛡️ Health Plans
- Recover improper payments before claims are finalized
- Reduce CMS, OIG, and state audit exposure
- Improve payment accuracy across Medicare, Medicaid, and Commercial lines
- Generate measurable savings and ROI on every accepted determination
- Recover improper payments before claims are finalized
👥 MSOs
- Audit delegated risk and capitated claims with AI
- Standardize reimbursement decisions across provider groups
- Reduce manual coding research and staffing costs
- Improve compliance while maximizing shared savings
- Audit delegated risk and capitated claims with AI
❤️ PACE Organizations
- Validate complex Medicare and Medicaid reimbursement rules
- Improve payment accuracy across interdisciplinary care
- Detect coding conflicts before claims are submitted or paid
- Maintain compliance with evolving CMS and PACE regulations
- Validate complex Medicare and Medicaid reimbursement rules
🩺 IPAs
- Protect capitated revenue by identifying improper payments
- Validate coding and reimbursement across contracted providers
- Improve compliance without increasing examiner workload
- Gain visibility into coding trends and provider performance
- Protect capitated revenue by identifying improper payments
📈 Medical Groups
- Maximize reimbursement while preventing improper payments
- Reduce financial risk under value-based and capitated contracts
- Identify coding errors before they impact revenue
- Improve payment accuracy without adding staff
- Maximize reimbursement while preventing improper payments
📋 TPAs
- Reduce administrative costs through AI-powered claims auditing
- Improve payment accuracy for self-funded employer health plans
- Deliver measurable savings and stronger client retention
- Standardize reimbursement decisions across multiple clients
- Reduce administrative costs through AI-powered claims auditing
The AI Claims Auditing Process
Internal System
Connect your new VE Server to your claims software
Runs Nightly
The VE Server pulls claims and analyzes them
Suggests Actions
VE populates recommended denial or reductions in VR
You Decide
Log into VR and evaluate, make the decision yourself
You Customize
Customize reports, add edits and contracts, to expedite workflows
VE Identifies
Unbundling
Duplicates
Global Period Conflicts
New Patient misclassification
Compound with Comprehensive
Modifier Misusage and Abuse
Terminated Codes
Invalid Place of Service
Improper Diagnosis
Wrong Sex
480+ Reason Codes
VE Cross-Claim Auditing Logic
NCCI Edits
Medi-Cal and Medicaid edits
Full 3-year Episode of Care auditing
VE AI generated suggested actions
Build your own custom edits
References past claims numbers
HIPAA compliant, no PHI
FWA and Provider Profiling reports
Bi-weekly code and rule updates
DOFR and Contract module
Over 72 million total edits
How Virtual Examiner Fits Into Your Existing Workflow
Full integration within existing Infrastructure
Virtual Examiner is installed on a dedicated server within your organization's secure infrastructure—not in PCG's environment. During implementation, PCG installs the Virtual Examiner platform, configures over 72 million reimbursement edits, coding rules, and AI logic, then integrates VE with your existing claims workflow. Once implementation is complete, the system operates entirely inside your environment.
HIPAA Compliant and Secure
Since your VE database is handled and managed by you, and PCG only sends secured coding and rules updates every quarter, PCG never comes into contact with PHI. In our 30+ year history, we've never had a breach or disclosure.
Nightly Auditing by AI, Human Decisions by Day
Every night, VE audits your claims on your dedicated VE server and populates only the claim line items that require review in Virtual Reporter® (VR). Your claims examiners, auditors, and compliance staff can then choose which claims to audit and which denials and/or reductions to apply within your claims adjudication software.
Employee Access and Usage of VE
Virtual Reporter is securely installed on authorized employee workstations connected to your organization's internal network, giving claims examiners and compliance staff immediate access to AI-generated determinations each morning. User access and permissions are fully controlled by your organization and can be granted, modified, or revoked at any time.
VE Software Suite Deliverables
Virtual Reporter
Higher Savings and Compliance per Claim Line Item
VE's nightly determinations populate within Virtual Reporter. AI does the heavy lifting, while your team makes the administrative final decisions.
Save 1,000s of hours of cross-platform research
AI audits claims while you and your team sleep
Every reason to deny or reduce explained
Conflicting claims are documented for reference
Create your own specialized report workflows
Create your own denial/reduction reason codes
Upload your contract with the contract module
FWA & Provider Profiling
Identify Patterns. Prevent Risk. Take Action.
Virtual Examiner® organizes your claims data into actionable provider-level intelligence, analyzing billing patterns, utilization shifts, modifier abuse, and reimbursement anomalies across a full 3-year history. Instead of reacting to isolated claims, your team can identify systemic issues tied to specific providers, specialties, or groups—allowing for earlier intervention, stronger compliance oversight, and more defensible audit strategies.
Detect abnormal billing trends
Surface provider outliers and high-risk liability
Customizable and Filterable search parameters
Downloadable PDF and Excel formats
Virtual AuthTech® (VA) included
Stop coding issues at the point of entry
Virtual AuthTech® provides a real-time environment for teams to assess CPT®, HCPCS, modifiers, diagnoses, and pricing logic before submitting claims or approvals. Similar to Virtual Examiner®, it enables staff to test scenarios against CMS, Medicaid, and your DOFR and contract terms, ensuring accurate, consistent, and defensible decisions that influence claims or payments.
Validate codes, modifiers, during auth review
Simulate Claims Adjudication
Simulate Authorizations
Evaluate Contractual pricing per GPCI
Research Codes, modifiers, and rules
Database Updated every Quarter
Implementation and Training
Virtual Examiner® (“VE”) is deployed within your organization’s secure environment and integrated into your existing claims workflows with minimal disruption. Implementation includes remote installation, IT and operational kickoff sessions, system configuration, and full user acceptance testing to ensure accuracy before go-live.
Your team then undergoes structured onsite training using your own claims data, followed by ongoing quarterly updates and continuous determination and technical support. From day one, PCG ensures your system is not only operational—but optimized for accurate, compliant, and high-impact decision-making.
Kick-Off Meetings
PCG meets with your IT, Claims, and Compliance team members to discuss and establish the setup of the dedicated VE server, its requirements, all users that should have access to the VE suite, and set a 5-day training schedule.
Remote Installation and Testing
Our collective IT teams work together to get VE's database installed on your internal dedicated VE server. From there, we test VE's nightly auditing and VR population of problematic quarantined claims. The entire testing process takes 2-5 days.
VE Training & Week 1 ROI
PCG provides training on VE's modules and the usage of VA to research codes and pricing. Once the basics are complete, PCG trains you to use VE determinations on live claims to achieve a Week One ROI.
FWA Training
Based on your availability and comfort with VE, PCG provides two days of Fraud, Waste, and Training, how to use the FWA module, and gives insights on how to properly launch your first or best FWA investigation and provider outreach.
Technical and Determinations Support
Following implementation, PCG provides ongoing business-day technical support, assistance with Virtual Examiner determinations, and guidance on reimbursement rules and edit logic. Every quarter, your organization receives updates to secure code, pricing, and reimbursement logic, along with the PCG Quarterly Newsletter, which highlights CMS, AMA, Medicaid, industry changes, new software features, and best practices to help maximize savings, compliance, and system performance.
Technical Support for VE Suite
Determinations Support for Claims
Quarterly code and rule logic secure 1-way updates
Quarterly PCG Newsletter summarizing all changes
Onsite and Virtual additional training upon request
Annual client review meetings to re-establish needs
The FREE Audit Process
45-55 Minute Consult
1-3 Days Claims Upload Completion
1-2 Week Audit Analysis by PCG
2-3-Hour Meeting for Results and ROI
1-Week Proposal and Licensing Review
No Hard sells, just facts and strategies
Get Your Free Consult & Demo
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