Detect Fraudulent and Abusive Billing Patterns on Any Claim System
PCG Software’s proprietary Virtual Examiner® allows healthcare organizations to enhance their current claims adjudication system with more than 31 million claims edits per claim. The user-friendly, scalable 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.
Co-developed by HCIM and PCG Software, SymKey® Virtual Auto-Post™ seamlessly integrates with Virtual Examiner® to automate the posting of claim edit recommendations directly into the healthcare payer’s core claims transaction system, thereby eliminating this intensive and time consuming manual process. Virtual Auto-Post™ clients can realize the immense cost savings of Virtual Examiner®/Virtual Reporter™ without the need to add additional staff to manually update their claims.
Virtual Examiner® is a registered trademark owned by PCG Software, Inc.