PCG maintains more than 250 operational APIs and ETLs connecting HHS agencies in 31 states (and counting) to third-party verification data; this data is used to enhance public assistance application intake and eligibility determination processes, both directly and through configurable, stand-alone PCG applications.
State HHS agencies face unique challenges as they make sure their truly eligible constituents maintain seamless access to public assistance while also ensuring the integrity of public assistance eligibility decisions and improving the operational throughput of agency eligibility and enrollment staff.
While each of these challenges is unique, one proven solution is improving agency access to innovative, timely, and complete verification data. This can save money, reduce resource requirements, support “one touch” determinations, and expedite public assistance eligibility decision making timeframes.
For this reason, six of the country’s ten largest public assistance programs—and thirty-one of the country’s fifty states and the District of Columbia—rely on PCG public assistance eligibility data management solutions. Why?
- Data Source Expertise: PCG has established interfaces with every major data provider in the United States, from massive credit bureaus and information services providers to unique Silicon Valley and other data provider startups. PCG understands every single output data element provided by each of these providers and each element’s usefulness and applicability to HHS eligibility determination processes.
- Proven, Configurable Software and Applications: Whether an HHS agency adopts our acclaimed Instant Eligibility Verification System & API Gateway package (used by two of the country’s ten largest public assistance programs and two additional states), our automated Data Broker Service, our stand-alone AVS Portal, or any number of a dozen other configurable or customized data solutions—each of PCG’s solutions was designed in concert with agency public assistance staff and has been proven in live, large-scale public assistance eligibility and enrollment environments. In total, PCG processes more than one million automated data exchange transactions connecting state HHS agencies to critical third-party verification data each day.
- Data Provider Neutrality: Because PCG is data vendor neutral, we can offer our agency clients the best data competing commercial vendors have to offer, rather than just the best data a single vendor has to offer.
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Eligibility Policy and Operations Expertise: PCG doesn’t just provide HHS agencies with raw data; rather, we offer a full-service public assistance eligibility consulting practice. Since 1986, PCG has become a recognized national leader in Medicaid, SNAP, TANF, Child Care, and other benefit program eligibility. Our eligibility consulting practice is relevant because it directly informs the strategy, tactics, and approaches we adopt and continually refine when designing and deploying public assistance eligibility data management solutions and services for state government.
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Trust and Security: State HHS agencies know PCG and trust our commitment to ensuring the security and confidentiality of their most sensitive data. PCG leverages a secure, virtual private AWS cloud—combined with compliance with federal and state information security standards and certifications (e.g., HIPAA, FERPA, FIPS 140-2, FISMA, MARS-E, etc.)—to support the uninterrupted performance and security of our systems and solutions.
PCG has developed several fully configurable data management systems, multiplexers/API gateways, and predictive analytics solutions—each of which can be efficiently integrated into existing public assistance eligibility and/or enrollment systems and/or accessed through stand-alone PCG applications, exchanges, and data services, including:
PCG’s Instant Eligibility Verification System & API Gateway
PCG’s fully configurable, Cloud- and SaaS-based Instant Eligibility Verification System & API Gateway (IEVS) is an off-the-shelf product which centralizes agency access to a configurable menu of third-party verification data sources and policy-based predictive analytics. IEVS instantaneously uses this third-party data, predictive analytics, and “known” ineligibility and fraud profiles to automatically verify eligibility, flag ineligibility and fraud, and quantify the level of risk each area of the application represents as it relates to eligibility for every different public assistance program.
PCG’s IEVS also includes multiple alerts flagging mid-certification changes in client circumstances representing potential ineligibility, including new employment, out-of-state moves, incarceration, drug felonies, changes in household composition, and death. Additionally, PCG’s IEVS “learns” throughout any engagement by capturing and assigning additional risk to unique scenarios and applicant profiles resulting in ineligibility decisions.
PCG’s IEVS is supported and informed by our Data Broker Service, with which we connect HHS agencies and agency systems to hundreds of APIs and ETLs from federal, state, and commercial data sources through a single PCG API gateway.
Finally, PCG offers a click-through gateway allowing agencies to nearly eliminate the work needed to integrate PCG’s IEVS into your eligibility system. PCG allows eligibility technicians to submit requests within your existing eligibility system through an encrypted form, using a password provided by PCG, to a PCG-provided URL. PCG will then use the authentication token from the state’s single sign-on solution to validate the user, process the request, and display the responses back to the workers in a HTML report that appears within a new window (without actually being integrated into your system). This allows your eligibility technicians to access our IEVS results directly from within your existing eligibility system on a HTML report hosted by PCG without requiring a full integration.
Data Broker Services
HHS agency eligibility technicians are frequently tasked with accessing multiple, disparately located public and private systems to obtain the data needed to verify public assistance eligibility. This is unnecessarily time consuming, prone to error and oversight, and difficult to monitor to ensure compliance. PCG’s data broker service solves this problem by serving as a “one stop shop” for providing access to all of this disparately located data in a single location, accessible via either API or PCG’s stand-alone IEVS.
Because PCG is data vendor neutral, PCG is able to offer our agency clients the best data available from all data providers, rather than just the best data a single vendor offers. PCG maintains more than 250 API and ETL interfaces connecting HHS agencies to valuable federal, state, and commercial data used to verify eligibility for public assistance programs. PCG leverages our API gateway to allow our agency and integrated eligibility system clients to connect to any or all of these data sources via a single API call to PCG.
Further, HHS agencies are incentivized to separate the responsibility for managing interfaces with and access to third-party data sources from their integrated eligibility system vendors’ scopes of work. This separation helps ensure that in the event the agency decides to re-procure an eligibility system, they are not required to re-procure the expensive setup and maintenance of these third-party interfaces.
PCG’s 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 (optional), resulting in the generation of which custom outputs, extracts and/or on-screen HTML reports.
Member Eligibility Verification Services
PCG leverages our proven Instant Eligibility Verification System & API Gateway software package to perform one-time or ongoing member eligibility verification services on behalf of state and federal health and social services agencies. On each of these engagements, PCG configures our IEVS rules engine to reflect program and client-level eligibility policy, helping ensure that any PCG eligibility recommendations are informed by the exact eligibility policy associated with each specific client and/or client household.
PCG performs both total eligibility verification services, as well as targeted eligibility verification services focused on specific populations and/or client behaviors. For example, on behalf of one top-five state’s public assistance program, PCG performed a total eligibility review and found 8 percent of SNAP clients, 6 percent of Medicaid clients, and 5 percent of TANF clients to be ineligible. On behalf of another state, PCG’s eligibility verification targeted the resource-based eligibility of their Medicaid Long Term Care population and found nearly 8 percent of their existing clients to be ineligible.
PCG’s member eligibility verification services can be configured to automate the review and verification of some or all of the following client-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; and/or Alien Status.
Post-Public Health Emergency Maintenance of Eligibility Transition Services
PCG is assisting half a dozen states in successfully “unwinding” following the conclusion of the public health emergency (PHE). PCG offers a number of services and solutions designed to mitigate and reduce the impact of the post-PHE Maintenance of Eligibility (MOE) transition on health and human services (HHS) agencies, including:
- Eligibility Operations Staff Augmentation Services
- Member Locator Services
- Member Eligibility Data Matching Services
- MOE Transition PMO Services
Each of these services is designed to reduce workloads, increase the efficiency of eligibility redeterminations, reduce churn and support a smoother, more equitable return to business as usual following the PHE.
Automated SNAP Eligibility Recertification & Verification
HHS agencies are required to process millions of SNAP recertification forms by mail each year. Further, absent a reported change in circumstances that would render the member ineligible, these same agencies typically accept self-attestation without performing any verification. Significant agency resources are required to process all this mail while the lack of verification allows otherwise some ineligible clients to continue receiving assistance.
PCG has solved for both dilemmas by developing an Automated SNAP Eligibility Recertification & Verification solution. First, PCG can establish and host an HTML SNAP periodic income report/recertification form in HHS agency self-service portals allowing your SNAP clients to provide the required mid-certification reporting online, rather than via the mail, saving significant worker time. Second, PCG can instantly evaluate these recertification attestations against third-party verification data to confirm their accuracy. Third, PCG can flag any failed verifications (and the reasons why) and call your agency’s task management system with the flag.
This process would eliminate manual mail processing for a large percentage of any agency’s SNAP population while ensuring the integrity of your SNAP payments.
If your agency operates anything like the dozens of other public assistance programs across the country PCG works with, a huge portion of your eligibility technicians’ time is spent manually recertifying SNAP eligibility. Automating parts of this process and/or verifying reported client changes will drastically cut your eligibility technicians’ workloads while improving program integrity.
Asset Verification Systems and Services
PCG is one of 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 can connect 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 property, motor vehicle, aircraft, and watercraft assets contributing to resource-based eligibility decision-making.
PCG offers agencies multiple options for accessing our AVS, including via batch file exchange, real-time web services calls, or through our stand-alone AVS Web Portal, the country’s most used AVS software.
Automated Fraud and Abuse Detection Systems
Offices of inspector general, fraud investigators, and program integrity divisions require configurable, automated member fraud and abuse detection systems which eliminate manual, time-consuming activities by automating access to third-party data sources, analytics, and fraud and abuse “case clues.” Member program integrity efforts and investigations are frequently complex, time-consuming, and resource-intensive—often with limited opportunity for recovering overpayments.
PCG has solved for this dilemma by developing a lightweight, flexible, and fully configurable member fraud and abuse detection system, available via both API integration and as a stand-alone, PCG-hosted web application. PCG’s system not only automatically flags clients presenting ineligibility and/or fraud risk, it also quantifies the level of risk each client represents based on each criterion governing each type of assistance’s eligibility (e.g. identity, income, residency, citizenship, household composition, employment, out-of-state benefits, property, assets, etc.). This allows investigators to immediately zero in on those areas of the application representing fraud risk while eliminating the need to review those areas of the application representing limited or no risk.
Custom Integrated Eligibility System Design and Development
Finally, PCG leverages our deep bench of more than 800 health and social services agency subject matter experts to provide custom integrated eligibility system design and development services agencies across the country. Whether focusing on individual modules or components, designing critical features or functionalities, or conceiving and creating low-cost, fully configurable integrated eligibility systems, PCG maintains the expertise and experience to provide custom integrated eligibility system design and development consulting services.
Eligibility Quality Control and Business Process Improvement Solutions
On behalf of state and federal agencies, offices of inspector general, and state program integrity units, PCG provides eligibility quality control and eligibility business process improvement services. PCG’s solutions are designed to improve error rates, optimize business processes, identify training opportunities, and improve the timeliness of public assistance eligibility decisions.
PCG uses our fully configurable Eligibility Auditor & System Accuracy Assurance Engine application to provide both pre- and post-enrollment reviews of the accuracy of agency public assistance eligibility actions and decisions by auditing the following:
- the caseworker’s appropriate application of eligibility policy
- appropriate use of third-party electronic data sources
- adherence to application processing procedures
- validity of system inputs and calculations
PCG’s Eligibility Auditor & System Accuracy Engine is a fully configurable, Cloud- and SaaS-based audit, quality control, and performance monitoring case management system. PCG automates the capture of eligibility information from state systems and facilitates the definition, creation, execution, and monitoring of all post-enrollment quality assurance, audit, and/or error rate improvement activities. Eligibility Auditor is a self-contained case and workflow management system which makes establishing, executing, and monitoring the accuracy and quality of public assistance eligibility decisions efficient, configurable by state, and fully transparent.
As of 2022, PCG is the country’s only authorized Medicaid Eligibility Quality Control Review Services (MEQC) vendor.
Additionally, PCG reviews public assistance eligibility worker policies and procedures, systems and operational usage and workflows, application access points and customer service supports, program waivers, and organizational cultures and staffing models to identify opportunities for improvement, including opportunities to improve the efficiency and accuracy of worker eligibility decisions.
Managed Care Member Eligibility Monitoring Services
PCG has developed and deployed an automated managed care population eligibility monitoring solution that aims to ensure eligibility at the point of application, recertification, and every week in between. PCG’s managed care plan monitoring solution helps ensure that as members move out-of-state, are deceased, obtain new employment, receive benefits in another state, and/or experience changes in household composition, agencies are notified at least weekly of these changes. This ongoing eligibility monitoring supports state agencies in eliminating nearly 100 percent of capitated payments for members who should no longer be covered by managed care plans.
PCG’s managed care member eligibility monitoring service helps our agency clients can avoid expensive OIG findings, negative media headlines, and contentious relationships with your managed care plans by providing a layer of assurance that covered plan members should actually retain eligibility throughout the certification period.
PCG’s managed care member eligibility monitoring service is available via real-time or periodic data exchanges, either via batch or API, and can be integrated with agency task list monitoring solutions.
Threat Monitoring Services
PCG provides a real-time population threat monitoring service which addresses the problem that periodic, “snapshot in time” background checks present. On behalf of our agency and private clients, PCG provides real-time population monitoring solutions which aggregate tens of thousands of public and private sources to identify and alert our clients of any individuals 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.
PCG’s threat monitoring service is designed to ensure the safety of vulnerable populations, such as children, the elderly, and people with disabilities, by alerting organizations to staff misbehavior representing a potential risk to their vulnerable populations.
Current applications of PCG’s threat monitoring service include:
- monitoring in-home and institutional care givers
- monitoring school district staff, including teachers, coaches, volunteers, bus drivers, and more
- monitoring agency employees maintaining positions of authority and/or trust