Real-Time Claims Auditing
Real-time Claims Auditing Determinations populated right inside your Claim System
VE Software upgrade
Virtual Examiner Web Services™ (“VEWS”) extends the power of Virtual Examiner® into your live claims environment, allowing your systems to call VE logic in real time. Deployed on your own internal server, VEWS evaluates claims as they are created, edited, or adjudicated—returning structured recommendations before payment is released.
Instead of relying solely on overnight audits, your organization can surface coding conflicts, reimbursement issues, and compliance risks immediately—reducing downstream rework and preventing incorrect payments at the source.
NCCI, Medi-Cal, and Custom Edits
Look-back timelines dependent upon Client
Ability to use for future automated denials
PCG Hosted and Managed VA Live Server
HIPAA compliant, no PHI
Bi-weekly code and rule updates
Ability to Apply your Contracts
Over 72 million total edits
Two Deployment Models
Claim-Level Review
VEWS evaluates each claim independently using current coding rules, reimbursement logic, and configuration settings. This model is ideal for organizations with standard server capacity looking to introduce real-time validation into their workflows.
3-year Historical Auditing in Real-Time
For organizations with expanded server infrastructure, VEWS can apply full longitudinal analysis—leveraging up to three years of billed and paid claims history in real time. This enables detection of duplicate billing, frequency violations, and episode-of-care conflicts as claims are processed.
Transitioning to Automated Denials
After implementation, VEWS allows organizations to go beyond post-adjudication review by selectively automating claim outcomes using Virtual Examiner® reason codes.
VEWS provides real-time structured denials, reductions, and pending recommendations, each backed by clear, auditable reason codes that can be mapped to automation rules. This helps Licensees identify specific, high-confidence scenarios for automatic denial before payment.
Typical automation scenarios include clear cases like terminated codes, invalid place of service, gender mismatches, duplicate billing, frequency violations, and consistent reimbursement rules. More complex cases can still go through manual review to maintain control while gradually expanding automation.
Automation Integration & Execution Strategy
PCG powers decisions, You Program Triggers
VEWS delivers real-time claims auditing and structured reason codes, while your internal IT team or a third-party vendor configures automation within your claims platform. You decide which scenarios trigger automatic denials, reductions, or pends. Common use cases include NCCI edits, terminated codes, invalid place-of-service codes, diagnosis mismatches, and duplicate billing—applied consistently before payment. This approach enables phased automation, reducing manual review while ensuring that every decision remains compliant, auditable, and under your full control.
Let's Get Started
PCG is happy to explore VEWS integrations with both existing and new potential clients.
Client vs Prospective Client Deliverables
Current Client Process →
- 45-60 Minute consultation
- Planning of Amendment/SOW
- Proposal and Licensing Review
- Likely 2-4 weeks live
Prospective Client Process →
- NDA, BAA
- 3-Year Claims Audit (2-4 weeks)
- Presentation to Stakeholders
- ROI Impact and Proposal
- Licensing Review
- 30-90 Days Live & Operational
Contact Us
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