VE Contract Module
Reimbursement and Contract Intelligence
Validate contracted rates, reimbursement terms, fee schedules, and line-of-business exceptions against actual claims activity.
Term Contract Terms into Reviewable Claim Logic
Use Virtual AuthTech to research reimbursement requirements and Virtual Reporter® to compare expected payment terms against actual claim results. Your organization can review contracted rates, fee schedules, provider-specific terms, line-of-business requirements, and approved exceptions to identify where payments may not align with contract intent.
Review contracted rates and reimbursement terms
Compare fee schedules against actual claim payments
Validate provider-specific and line-of-business requirements
Identify overpayments, underpayments, and recurring variances
Apply approved contract exceptions and carve-outs
Detect coding, modifier, and reimbursement conflicts
Quantify affected claims and financial impact
Disclaimer: PCG identifies potential payment variances and contract-rule conflicts for client review. Your organization remains responsible for interpreting contract terms, approving reimbursement logic, and determining whether correction, recovery, or configuration changes are appropriate.
5 Reasons Contracted Reimbursement Is Difficult to Validate
Changing Fee Schedules
Rates, code sets, and reimbursement policies change frequently.
Provider Specific Terms
Different providers may have unique rates, exclusions, and payment rules.
Line of Business Variations
Medicare, Medicaid, and commercial terms may require different logic.
Manual Contract Research
Teams spend substantial time reviewing contracts, codes, and claims separately.
Limited Payment History Visbility
Recurring overpayments and underpayments may remain hidden across claims history.
Turning Contract Language Into Payment Intelligence
Establishing the Expected Payment First
A reimbursement variance cannot be identified until your team establishes what should have been paid. Using Virtual Reporter's Contract module, you can organize the applicable coding rules, fee schedules, contract terms, provider requirements, and approved exceptions.
Research the Applicable Terms →
Use Virtual AuthTech® to review procedure codes, modifiers, pricing references, reimbursement guidance, and related coding requirements to determine if your contract guidelines and pricing is based on national best business practices and rates.
Define the Expected Payment →
Identify the applicable contracted rate, fee schedule, payment methodology, provider-specific term, and line-of-business requirement based on your local GPCI.
Compare Against Actual Claims →
Use Virtual Reporter® to review paid amounts, allowed amounts, reductions, modifiers, and other claim-level results against the expected terms.
The VE Contract Module Diagram
Let's Get Started
Whether you already use Virtual Examiner® or are evaluating PCG for the first time, we will help you determine the most practical approach to reimbursement and contract validation.
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