About
PCG Software is a leading provider of AI-driven medical coding, claims auditing, and healthcare compliance solutions designed for payers, MSOs, PACE organizations, providers, and healthcare consultants. Their flagship platform, Virtual Examiner® (VE), is the world's only full episode-of-care claims auditing solution that automatically identifies problematic claims, explains what's wrong with them, and suggests appropriate denials, reductions, or pends for contractual review. Built on 30+ years of quarterly coding and rules updates across CMS, AMA, and Medi-Cal, PCG maintains the world's largest AI medical coding and compliance database. Their suite of solutions includes Virtual Examiner for payer claims auditing and FWA detection, VA Live for authorization denial automation based on CCI or custom edits, VEWS for claims automation workflows, and iVECoder for provider-side AI coding support. PCG serves over 170 payer organizations—from those with a single line of business to those with 200 lines—and consistently delivers ROI within 90 days for 99% of clients, even when applying only 75% of suggested denials. The platform enables healthcare teams to stay ahead of CMS, AMA, and Medicaid requirements, reduce incorrect claim payouts, improve encounter data quality, and mitigate risk of CMS audits and de-delegation. Medical billing companies can also integrate PCG's code scrubber via VEWS.
Key Features
- Virtual Examiner® Claims Auditing: The world's only full episode-of-care claims auditing solution that flags problematic claims, explains coding errors, and suggests denials, reductions, or pends for review.
- World's Largest AI Coding & Rules Database: 30+ years of quarterly updates covering CMS, AMA, and Medi-Cal rules ensure the most comprehensive and current medical coding compliance database available.
- Authorization & Claims Automation (VA Live / VEWS): Automate authorization denials based on CCI or custom edits, and streamline claims denial workflows through integration with automation partners.
- Provider-Side AI Coding (iVECoder): Empowers providers and medical billing companies with AI-assisted coding suggestions to improve accuracy before claims are submitted to payers.
- Fraud, Waste & Abuse (FWA) Detection: Proactively identifies patterns of fraud, waste, and abuse within claims data to protect organizations from financial losses and CMS audit risk.
Use Cases
- A regional health plan uses Virtual Examiner to automatically audit all incoming claims for CCI violations and upcoding, reducing overpayments by millions annually.
- A PACE organization leverages PCG's FWA detection to flag suspicious billing patterns and protect against CMS audit risk and potential de-delegation.
- A medical billing company integrates VEWS as a code scrubber to validate claims before submission, improving clean claim rates and reducing rework.
- An MSO deploys VA Live to automate prior authorization denials based on clinical criteria, freeing up staff for higher-complexity reviews.
- A healthcare consultant uses PCG's audit findings and compliance database to advise payer clients on meeting evolving CMS and AMA coding requirements.
Pros
- Rapid ROI: 99% of clients achieve a measurable return on investment within 90 days, even when applying only 75% of VE-suggested denials.
- Comprehensive Coverage: Supports payer organizations of all sizes—from 10,000 to 5 million+ lives—across CMS, AMA, and Medicaid requirements.
- Free Audit Offering: Organizations can claim a free payer claims audit to evaluate the real-world impact of Virtual Examiner before committing.
- Proven 30-Year Track Record: Over three decades of experience with 170+ payer organizations gives PCG deep domain expertise and regulatory credibility.
Cons
- Enterprise-Focused Pricing: PCG Software is built for mid-to-large payer organizations; pricing and implementation complexity may be prohibitive for small practices or startups.
- Limited Transparency on Pricing: No public pricing is available—organizations must contact sales and go through a consultation process to get a quote.
- Payer-Centric Primary Focus: While iVECoder serves providers, the core platform is designed around payer workflows, which may limit utility for provider-only organizations.
Frequently Asked Questions
What is Virtual Examiner® (VE)?
Virtual Examiner® is PCG Software's flagship AI claims auditing solution. It analyzes claims across the full episode of care, identifies coding errors or inappropriate billing, and suggests whether to deny, reduce, or pend claims for review—helping payers avoid overpayments and stay compliant.
Who is PCG Software designed for?
PCG Software primarily serves payer organizations including Health Plans, MSOs, PACE organizations, TPAs, IPAs, ACOs, and CCOs. They also offer provider-side tools like iVECoder for providers and medical billing companies.
How quickly can organizations see ROI from Virtual Examiner?
PCG reports that 99% of clients see a positive ROI within 90 days of deploying Virtual Examiner, even when applying only 75% of the platform's suggested claim denials.
Does PCG Software offer a free trial or audit?
Yes. PCG offers a free payer claims audit where they demonstrate Virtual Examiner's impact on your actual claims data within 30 days, allowing you to assess ROI before purchasing.
What is the difference between VA Live and VEWS?
VA Live is an authorization denial automation tool exclusive to existing VE clients that automates denials based on CCI edits or custom rules. VEWS (Virtual Examiner Web Services) enables claims automation and code scrubber integrations for medical billing companies and other workflow systems.
