PCG’s Virtual Examiner fraud and abuse prevention software deployed at San Diego’s Community Health Group

Sep 9 2009

PCG Software, a leading provider of software solutions designed to ensure proper and accurate payment of medical claims for healthcare payer and provider organizations, today announced that Community Health Group (San Diego) has deployed PCG’s Virtual Examiner fraud and abuse prevention software.

According to Joseph Garcia, Community Health Group’s chief operating officer, the organization had been searching for more than five years for an automated auditing tool to enhance the claims adjudication process: “We wanted to enhance our regulatory compliance efforts to detect billing errors and/or unfair billing practices in the most efficient manner. For years, we’ve been looking for an automated system that was robust enough for our needs and we found it in PCG’s Virtual Examiner.”

Community Health Group also uses data generated by Virtual Examiner in its provider-relations efforts. Because Virtual Examiner pinpoints the exact reasons a claim is improper, the payer shows providers the rule, rate or applicable regulation that caused the claim to be adjusted or denied. As a result, providers across the board have corrected many long-term errors in their billing processes.

“Virtual Examiner helps us fulfill our essential regulatory responsibilities along with managing healthcare efficiently and effectively,” Garcia asserts. “For health plans like ours, Virtual Examiner is a low-risk proposition. The savings are there, and the system pays for itself very quickly. Even more importantly, we can partner with our providers to ensure proper coding and payment in the most effective manner.”

Virtual Examiner is a cost-containment solution that evaluates claims for proper billing and identifies claims that may involve third-party liability/coordination of benefits, case management opportunities, physician billing education and many other cost recovery possibilities.

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