✅ Plans, MSOs, and PACE Organizations
✅ Real-Time Authorization Determination
✅ Epic, EZ-Cap, Plexis, and QuickCap
✅ Auto-Deny or Auto-Approve
✅
Customizable to Your Business
Available to VE Suite Customers only
Automate Your Authorizations
VEWS is your Real-Time Authorizations Evolution
VEWS extends the Virtual Examiner® Suite into real-time authorization decision support, allowing plans, MSOs, and PACE organizations to validate authorization requests at the moment they are submitted. Rather than relying on post-decision audits or manual nurse review queues, VEWS applies CMS rules, AMA guidance, medical necessity logic, payer-specific policies, and historical VE intelligence to each authorization in real time. The result is faster, more consistent determinations, fewer downstream denials, and clear, defensible reasoning for every approval, pend, or denial — all delivered directly inside your existing authorization platform.
Real-time Authorizations
What is required to get Auths automated?
Successful authorization automation starts with preparation, not technology. Before VEWS can drive real-time decisions, payers must define how authorizations are reviewed, which rules apply by line of business, and where automation is appropriate versus clinical judgment. VEWS does not replace utilization management policy—it operationalizes it. When your authorization rules, coverage criteria, and routing logic are clearly defined, VEWS applies them consistently and instantly inside your existing systems.
Mapping Your Authorization Codes & Rules
To automate authorizations, your team must first map procedure codes, diagnosis requirements, provider types, places of service, and plan-specific coverage rules. VEWS relies on this configuration to understand which services require prior auth, which conditions must be met, and which requests are eligible for straight-through processing. This upfront mapping ensures that Medicare, Medicaid, and commercial policies are applied correctly and consistently across all authorization requests.
Defining the Rules of Automation Stop and Start
Not every authorization should be automated. VEWS requires clear thresholds for when requests are approved, denied, pended, or escalated to clinical staff. Plans define what qualifies as routine versus complex, what triggers medical director review, and which scenarios must remain manual. VEWS enforces these guardrails in real time—preventing inappropriate auto-decisions while removing low-risk requests from clinical queues.
VEWS Logic is the backbone for Suggested Decisions
Once rules and workflows are defined, VEWS applies real-time validation to every authorization request. Incomplete submissions, non-covered services, policy conflicts, and medical necessity gaps are flagged immediately with clear reasoning and recommended actions. Requests that meet all requirements move forward without delay, while exceptions are routed appropriately—creating faster decisions, fewer appeals, and a defensible audit trail for every determination.
Working with Automation Companies
PCG has Authorization Automation Partners
True authorization automation requires more than technology—it requires correct clinical logic, regulatory alignment, and disciplined execution. VEWS provides the real-time, defensible authorization determinations, while automation partners operationalize those determinations inside your existing authorization and utilization management systems. These partners bring deep medical management, utilization review, and compliance expertise, translating VEWS outputs—approval, denial, pend, or escalation—into automated actions that execute consistently within your workflows.
Rule ownership remains with the client. Payers define which services require authorization, applicable clinical thresholds, exception handling, and when human review is required. VEWS enforces those rules uniformly in real time, and automation partners configure system behaviors to execute them—ensuring every automated authorization decision is compliant, auditable, and defensible while preserving full payer control over policy design and risk tolerance.
Client Results & FREE Audits
VEWS is an Add-on to VE
Before launching VEWS, we provide a free full 3-year claims audit to show what VE would have found and what VEWS will automate going forward. This analysis uncovers missed denials, reductions, improper payments, and high-risk patterns your team could not have caught manually. These findings become your roadmap: how VEWS will automate claims, streamline authorizations, and prevent future overspend the moment your system goes live.
What do we need to start a FREE audit
You’ll sign a Mutual NDA and BAA, then securely send three years of claims data. We analyze the data for 3–5 weeks and return a full findings presentation including dollar savings, compliance exposure, duplicate trends, and ROI projections. This audit is completely free and requires no commitment.
How our clients getting a 90-Day positive ROI?
Most organizations see ROI in under 90 days because VE immediately identifies duplicate payments, incorrect codes, global conflicts, and unbundled procedures. These savings occur before your team even finishes implementation. VE’s combination of automation and accuracy is the reason payers see measurable results faster than any other claims auditing software.
How does implementation and training work?
Installation is completed in 1–2 weeks on your secure intranet. We then conduct a 5-day onsite training with your Claims, SIU, and Medical Management teams. Week One you are fully operational, auditing live claims, and generating immediate savings. No lengthy onboarding, no outsourcing, no delays.
How to Get Started with VE and VEWS
1
VE and VEWS Consult
Have a 45-minute discovery call with our CSO to discuss your needs, explore how VEWS automates claims and authorizations in real time, and ensure your systems (Epic, EZ-Cap, Plexis, QuickCap, etc.) are ready for integration. If the fit is right, we’ll proceed to the VE audit and VEWS automation planning.
2
3-Year Claims Audit Analysis
Once the NDA and BAA are signed, submit three years of claims data. In 3–5 weeks, we will conduct VE’s episode-of-care audit to identify missed denials, reductions, improper authorizations, and automation opportunities. These findings will outline what VEWS will automate, the savings achieved, and real-time determinations.
3
On-Site Audit Reveal
We meet with your decision-makers to present the VE audit, projected VEWS ROI, and an automation plan for claims, authorizations, routing, and integrations. We discuss options for real-time determinations, automated denials, and provider insights. After approval, we finalize the contract and begin implementation.
4
Implementation and Go-Live
After signing the agreement, we start VEWS installation and system integration with Epic, EZ-Cap, Plexis, or QuickCap. We hold configuration meetings with your automation company, map decision logic, and conduct testing and validation. Your Claims, Medical Management, and IT teams receive training as automated processes are gradually activated. Once testing is validated, VEWS goes live—offering real-time auditing, compliance, and automation from Day One.
