PCG TPA Services

PCG’s broad range of services enable our clients to choose between a limited range of administrative services (ASO) up to a full-service TPA arrangement.

Our arrangements typically include:

  • Claims Payment and Customer Service. PCG-TPA provides customized claims payment services, tailored specifically to your plan or program. We provide accurate and timely processing of claims and exemplary customer service.

  • Payment Integrity and Cost Management. PCG-TPA’s core services include claims editing, clinical bill review and auditing, specialty clinical audits, dialysis savings and support, and out-of-network provider bill review.

  • Maintenance of Benefits Enrollment and Membership Eligibility. PCG-TPA understands that managing the enrollment process and change events are a pressing concern for our clients and their members and we ensure membership information is timely and accurate. We maintain the flexibility to accept various forms of source enrollment data including acceptance of standard EDI 834 files.

  • Maintenance of Healthcare Provider Fee Schedules and Records. We utilize a state-of-the art claims platform to ensure all records are accurate and secure.

  • Network Solutions. PCG-TPA can help with your network design, management, and access, and we provide a broad range of national, regional, local, and specialty networks.

  • Membership and Claims Inquiry Portal. PCG-TPA utilizes a robust integrated online service enabling our clients, their members, and healthcare providers to securely access online eligibility data and claim status information.

  • Office Services. PCG-TPA is adept at preparing summary plan descriptions for employees, preparing administration manuals, and issuing Member ID Cards and enrollment information for printed or electronic delivery.

  • Audit Support and Regulatory Compliance Assistance. Our team applies decades of Medicare and Medicaid experience when assisting clients through routine audits and responding to findings, if any. PCG-TPA offers compliance assistance and can help determine how changes apply to each unique plan as well as the best implementation strategy.

  • Fraud, Waste & Abuse Expertise and Program Integrity. We apply best practices from our national program integrity consulting services to claims processing protocols. PCG-TPA is a leading expert in developing and delivering new and innovative approaches to a full range of program integrity functions, including pre- and post-payment reviews, audits, investigations, and data analytics.

Finance and Reporting Services

  • Premium Billing, Collection, and Remittance of ancillary lines of business. PCG-TPA offers an easy collection and remittance solution. Our integrated solution handles collection of premiums for multiple plans and carriers. Complete reconciliation and reporting back to the carriers is provided.

  • Health Plan Analytics and Predictive Modeling. PCG-TPA does not just collect data – our tools and experience have taught us to turn that data into powerful analytics that can drive your plan and operational decisions. Utilizing dynamic, web-based Tableau reporting capabilities, we offer our clients a range of analytic opportunities.

  • Broad and Robust Suite of Reporting. PCG-TPA offers a robust set of standardized health plan reports, as well as the flexibility to accommodate ad hoc reporting requests. Our Reporting Unit can help you modify existing reports and create dynamic reports for your use. Our TPA team includes consultants experienced in analyzing data and translating data into useful reports that comply with each government’s requirements and standards.

  • Value Based Purchasing (VBP). PCG-TPA can help you reward value, not volume. We provide a robust data analytics platform that can seamlessly pinpoint opportunities for VBP payment reform. We use this platform to identify instances, specific services, programs, and/or procedures that have high payment variability due to complication costs, unnecessary services, and readmission rates. Services include:

    • VBP Design Modeling
    • Reference-Based Pricing
    • Fiscal Impact Analyses
    • Stakeholder Training
    • VBP Implementation and ongoing Operational Support