Claims

PGBA has three decades of experience in providing scalable, flexible claims processing solutions. Our vast technological infrastructure allows us to deliver customized solutions for plans with wide fluctuations in claim and membership volume.

But it's our people that bring the real value. Our highly specialized claims workforce delivers the expertise needed to meet the financial performance and compliance requirements of every PGBA client. From prepayment and claims review to claims pricing and overpayment recovery, we make a bottom-line difference every day for our clients as we provide high-volume, highly accurate claims processing services. The numbers are there to prove it.

Processing

PGBA currently processes more than 50 million claims a year, with 99% of clean claims processed in 30 days. The system supporting PGBA has the capacity to process over a million claims transactions per day. It operates in an IBM SysPlex environment that provides virtually unlimited data center scalability.

Prepayment

We have long provided health plans with prepayment review and pre and post payment utilization review as part of our claims services. Using nurses with multi-state licenses from the state of South Carolina, we've not only reviewed claims for medical necessity, but also tracked and monitored provider behavior in the TRICARE, Medicare and Medicaid lines of business. This experience demonstrates our full appreciation for the complexities associated with safeguarding federal and state funds from potential fraud and abuse.

Pricing

PGBA's proven pricing solution is scalable and flexible, which allows us to customize our processes to a wide range of healthcare plans. We have a single, centralized source for pricing information that ensures timely maintenance of pricing updates. We then apply this pricing data across the entire enterprise to appropriately price claims for health plans.

Review

Our team of claims review professionals, many of whom have medical backgrounds, has the expertise required to make informed decisions about a provider's billing practices. Their skills in comparing procedures claimed against a prescriptive set of coverage policies help PGBA prevent overpayments and, in some cases, initiate recovery efforts to reclaim misspent funds. Their ability to review medical documentation to determine a procedure's medical appropriateness is instrumental in accurately disbursing funds in accordance with benefit limitations and provider specialty considerations.

Recovery

To recoup funds owed by providers and beneficiaries, PGBA has formal procedures to identify overpayments, then request and collect payment. We identify overpayments through quality control reviews, internal and external audits, and contact with providers and beneficiaries.

Document control

PGBA controls the receipt and storage of paper documents, including claims, correspondence and medical records. Our document control center uses high resolution scanning and imaging equipment to convert paper documents into electronic files. A separate records retention area allows us to file all original hard copies for disposition in accordance with individual contractual terms and obligations.

Electronic files come directly into our electronic data interchange gateway (EDIG) for routing and storage. We configured this system to accept all standardized electronic transactions and code sets required under the administration simplification section of HIPAA. The result has been a streamlined method for customers to securely submit data faster.