Member Eligibility Verification Data Broker Services

PCG specializes in designing and deploying creative systems and solutions which allow agencies to replace manual application review activities with data and analytics in order to enhance the integrity of public assistance membership files.

PCG currently processes more than 2 million benefits eligibility verification transactions every day on behalf of more than 2 dozen state health and human services agencies. Each transaction automates the comparison of data from one or more state, federal and/or commercial data sources with the applicant’s identity, attestations and program requirements to verify eligibility, flag changes in eligibility and highlight any instances of potential fraud.

Our member eligibility verification data broker services include:

  • Automated eligibility verification services
  • Managed care population eligibility monitoring services
  • CMS-compliant asset verification services (AVS)
  • Benefits eligibility redetermination services
  • Medicaid Eligibility Quality Control (MEQC) Review Services
  • Predictive analytics design services
  • Threat monitoring services
  • Eligibility verification technology development services

 

Data Broker Services


PCG maintains established APIs and ETLs with dozens of federal, state and commercial data sources via our enterprise-class data hub. On behalf of our agency customers, we serve as a “one stop shop” for managing the access to and integration of this data. Our data broker service is designed to establish a single API or batch interface between the agency and PCG’s data hub, allowing the agency to avoid developing and maintaining dozens of custom and costly connections with third party data sources.

Our data broker service includes defining a configurable rules engine to dictate what agency inputs and/or scenarios should result in the querying of which data sources, to be evaluated against which program limits and business rules, resulting in the generation of which custom outputs, extracts and/or on-screen reports.

Because we are data vendor-neutral, we are able to offer the most comprehensive menu of identity and eligibility verification data sources from competing commercial vendors in a single, comprehensive solution. 

Member Eligibility Verification Services


PCG designs and integrates custom member eligibility verification services for our agency customers that ensure: (1) the agency is connected with the critical federal, state and/or commercial data sources needed; (2) the agency can connect to this data in the most convenient manner possible, including via batch, API, or our stand-alone, web-based solutions; (3) this data is complemented with a configurable agency and program-specific analytics rules engine; and (4) the total solution maximizes the agency’s ability to expedite application processing timeframes and identify ineligibility and/or fraud.

Our member eligibility verification services will automatically flag and verify some or all of the following criteria potentially impacting eligibility based on member-level program limits and requirements:

  • Fraudulent Behavior
  • Identity
  • Address
  • Death
  • Incarceration
  • Criminal History
  • Credit History
  • Citizenship
  • Unearned Income
  • Earned Income
  • Household Composition
  • Undisclosed Earners
  • Caretaker Relative Ages
  • Self-Employment Income
  • Undisclosed Income Sources
  • New Hires
  • Marriage
  • Divorce
  • Dependent Statuses
  • Financial Assets
  • Property Assets
  • Motor Vehicles
  • Aircraft
  • Watercraft
  • Undisclosed Bank Accounts
  • Disqualifying Asset Transfers
  • Undisclosed Property Ownership
  • In-State Residency
  • Out-of-State Benefits Eligibility
  • Intentional Program Violations
  • Lottery Winnings
  • Child Support Participation
  • Unemployment compensation
  • Alien status

 

Managed Care Member Eligibility Monitoring Services


PCG has developed and deployed an automated managed care population eligibility monitoring solution which ensures eligibility at the point of application, renewal and every week in between. PCG’s MCO monitoring solution ensures that as members move out-of-state, are deceased, obtain new employment and/or receive benefits in another state, agencies are notified at least weekly of these changes. This ongoing eligibility monitoring ensures state agencies can eliminate 100 percent of capitated payments for members who should no longer be covered by managed care plans. 

PCG’s managed care member eligibility verification service can focus on a few key areas of eligibility – such as ensuring each week that you don’t continue to pay for managed care members who have died, moved out of state, have recently been hired and/or are receiving benefits in another state – or automate nearly the entire benefits eligibility determination and redetermination process.

PCG’s eligibility verification data matches go beyond simply comparing data to program limits. For example, when verifying the income component of eligibility, most eligibility verification vendors simply compare one or two income data sets to program limits to verify income-based eligibility.  PCG still does this, of course, but we also look for anomalous data, relationships, and connections between the data which might also suggest potential ineligibility and/or fraud.

PCG’s managed care member eligibility monitoring service is available via real-time, weekly or monthly data exchanges as either batch or web services calls.

Asset Verification Services


PCG is the country’s most experienced Medicaid asset verification services (AVS) vendor. Since 2012, PCG has been engaged by dozens of states to implement and operate CMS-compliant asset verification services.

Our asset verification service connects agencies with 100 percent of the financial institutions in the United States to verify account ownership potentially impacting resource-based benefits eligibility. PCG’s asset verification services are designed to help our agency partners achieve the following goals: (1) eliminate the need for your workers to manually collect and review physical bank statements, except from those clients PCG identifies as exceeding program resource limits; (2) identify undisclosed bank accounts; (3) verify the account balances of disclosed bank accounts; (4) identify disqualifying asset transfers; and (5) flag the need for a client to spend-down assets before eligibility is approved.

Our asset verification services can be enhanced through the inclusion of not just financial assets potentially impacting eligibility, but also with real and personal property assets contributing to resource-based eligibility decision-making.

We offer agencies multiple options for accessing our AVS, including via batch file exchange or real-time web services calls or through our stand-alone AVS Web Portal, the country’s most used AVS software.

Medicaid Eligibility Quality Control Review Services


On behalf of State Medicaid agencies, offices of inspector general, and state program integrity units, PCG provides Medicaid Eligibility Quality Control Review Services. In this capacity PCG developed and deployed a CMS-compliant review tool used to efficiently and accurately review prior positive and negative Medicaid and CHIP eligibility decisions. PCG’s reviews assist the State in identifying overpayment rates, capturing business process improvement opportunities, and improving the accuracy and efficiency of future eligibility decision-making. Specifically, PCG’s eligibility review team performs a retrospective review of worker eligibility decisions by validating: (1) the caseworker’s application of eligibility policy; (2) use of electronic data sources; (3) application processing procedures; (4) system inputs and calculations and (5) the final eligibility decision.

Threat Monitoring Services


PCG provides a real-time provider owner and staff threat monitoring service which solves the problem that periodic, “snapshot in time” background checks present. PCG monitors Medicaid provider owners and staff in real-time and alerts the agency within 24 hours anytime a subject is involved in a law enforcement situation related to abuse, neglect, violence, fraud, theft, criminal sexual conduct, weapons, felony motor vehicle, and/or drug use anywhere in the United States. This solution ensures that safety of patients and other staff and the integrity of the agency’s payments to the provider.