Third Party Administrator (TPA) Services
PCG serves as an expert and trusted third party administrator (TPA) providing end to end claims processing services and solutions on behalf of government agencies and health plans. Our team works with Medicare and Medicaid health plans, as well as other government state agencies to perform critical business functions on behalf of their health care programs.
By trusting PCG to perform TPA functions, you can increase the accuracy and timeliness of claims processing, thus allowing your staff to focus on more important and strategic program functions.
How can PCG help?
- Non-Traditional Provider Support and Expertise – With a highly personalized and flexible TPA business model, we can accept a variety of standard and non-standard formats for claim submission to support providers that deliver non-healthcare related services, particularly long-term services and supports (LTSS). PCG has a long history of providing TPA services which extend to Medicaid and Medicare dual eligible populations, LTSS, elder services programs, child welfare, early intervention, mental health, and developmental disability.
- User-Friendly Web Portal – Our web portal is available 24/7, allowing for real-time claim submission and inquiries into claim status and member eligibility. This promotes provider self-service and increased access to information needed to continue serving members.
- Fraud, Waste, and Abuse Expertise – We apply best practices from our national program integrity consulting services to claims processing protocols. PCG 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.
- Customer Service – Our service representatives provide responsive and attentive service to providers through a toll-free phone number and written correspondence. The customer service model employed by PCG is hands-on, often working directly with providers to resolve claiming issues such as rate of payment disputes and prior approval inquiries. PCG also regularly works with clients to address any matters concerning member services to bring about a prompt resolution.
- Regulatory Compliance Assistance – PCG offers compliance assistance and can help determine how changes apply to each unique plan as well as the best implementation strategy.
- Forecasting, Budgeting, and Reserve Setting – We can provide payment projection analysis to allow for informed financial management within the health plan.
- Centers for Medicare and Medicaid Services (CMS) Audit Support – PCG applies decades of Medicare and Medicaid experience when assisting clients through routine audits and responding to findings, if any.
- Benefits Administration, Prior Authorization Management, and Fee Schedule Development – Our team of healthcare experts can design and implement all critical aspects of a successful claim shop. Ongoing maintenance ensures that the needs of the health plan and its members are being met.
- Paperless Claims Administration – PCG’s claims administration process is capable of being 100% paperless. Through the web portal, providers can enter claims directly into our claim system with ease, whether it be a single claim or HIPAA-compliant files. We can also work with providers’ clearinghouses to accept HIPAA-compliant files, and providers can choose to receive electronic payment in place of a paper check. PCG has run successful campaigns to encourage providers to go paperless, even cutting paper claim submission in half for one health plan.
Proven Results
- $2+ Billion - PCG processes over $2 Billion in healthcare payments annually to more than 150k providers and 110k consumers.
- 15+ Years – Our team has been providing claims administration services for both public and private entities for over 15 years.
- 26 States – PCG serves as an administrator for more than 50 programs across 26 states.
Interested in learning how our TPA services can support and streamline claims processing for your agency or health plan? Contact us today for more information.