PCG has developed several fully configurable member eligibility verification systems, multiplexers/API gateways, and predictive analytics solutions, each of which can be efficiently integrated into existing public assistance eligibility systems and/or accessed through stand-alone PCG eligibility verification applications.
PCG’s member eligibility verification systems and services allow our state and federal agency clients to efficiently replace manual application review activities with third-party data and analytics to enhance the integrity of their public assistance membership files. More than 30 health and social services agencies are currently processing more than 2 million eligibility verification transactions through our systems every single day. 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.
PCG maintains and supports multiple modules contributing to the verification of public assistance eligibility, each of which are available either on their own or as a single, fully integrated solution, PCG’s “Instant Eligibility Verification System”, including:
- PCG maintains more than 120 API and ETL interfaces connecting our systems to valuable federal, state, and commercial data used to verify eligibility for public assistance programs. PCG’s multiplexer or API gateway service modules 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.
- PCG’s rules engine module allows these same clients to efficiently configure and define the business rules dictating how calls to our service are processed and responded to.
- PCG’s data analytics module allows us to quickly configure our predictive analytics rules and data matches to align with agency eligibility policy.
- PCG’s eligibility verification user interfaces allow our clients to independently access our system(s) via the Web.
Additionally, PCG’s member eligibility verification systems and services, include:
- PCG’s Instant Eligibility Verification System
- Eligibility redetermination services
- Data broker services
- Asset verification systems and services
- Automated fraud and abuse detection solutions
- Managed care population eligibility monitoring services
- Eligibility quality control and business process improvement solutions
- Population Monitoring System
- Custom integrated eligibility system design and development
PCG’s Instant Eligibility Verification System
PCG’s fully configurable, SaaS-based Instant Eligibility Verification System (IEVS) is an off-the-shelf product which centralizes agency access to a configurable menu of third-party data sources and policy-based predictive analytics. IEVS instantaneously uses this third-party data and predictive analytics 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.
The goals of PCG’s IEVS are to 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.
By centralizing your eligibility technicians’ access to dozens of third-party data sources, PCG’s IEVS improves both the accuracy and efficiency of public assistance eligibility decisions while highlighting “case clues” and known scenarios representing potential ineligibility and/or fraud.
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 resulting in ineligibility decisions.
Available via either API, batch, or via PCG’s stand-alone IEVS web application, three states (and counting) have adopted PCG’s complete IEVS to improve the accuracy and efficiency of their public assistance eligibility decisions, resulting in more than five percent of eligible clients being disenrolled due to previously undiscovered client issues impacting eligibility.
PCG’s IEVS is a complete, self-contained system which combines our API gateway, rules engine, and data analytics platforms with task management, letter generation, and reporting dashboard features.
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, and then having PCG 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.
Member Eligibility Verification Services
PCG leverages our Instant Eligibility Verification System 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 data analytics platform to reflect program and client-level eligibility policy, ensuring that any PCG eligibility recommendations are informed by the 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-three state’s public assistance program, PCG performed a total eligibility review and found eight percent of SNAP clients, six percent of Medicaid clients, and five 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 eight 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
- Criminal History
- Credit History
- Unearned Income
- Earned Income
- Household Composition
- Undisclosed Earners
- Caretaker Relative Ages
- Self-Employment Income
- Undisclosed Income Sources
- New Hires
- Dependent Statuses
- Financial Assets
- Property Assets
- Motor Vehicles
- 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
Data Broker Services
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 120 API and ETL interfaces (and counting) connecting our systems to valuable federal, state, and commercial data used to verify eligibility for public assistance programs. PCG leverages our multiplexer or API gateway modules 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.
Health and social services agency eligibility technicians are frequently tasked with accessing multiple, disparate 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.
Further, state health and social services 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 ensures 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, resulting in the generation of which custom outputs, extracts and/or on-screen HTML reports.
Asset Verification Systems and 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 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 Eligibility Audit web 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
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.
PCG Eligibility Audit tool is a fully configurable, Web-based audit and evidence management system which includes CMS-compliant program error codes while supporting CMS-required reporting.
To date, PCG is the country’s only authorized Medicaid Eligibility Quality Control Review Services (MEQC) vendor.
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, recertification, and every week in between. PCG’s managed care plan monitoring solution ensures 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 ensures state agencies can eliminate 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 ensures 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.
Post-Public Health Emergency Eligibility Redetermination Catch Up Services
With the onset of COVID-19 and the ongoing Public Health Emergency (PHE) designation, states have been forbidden from disenrolling ineligible Medicaid clients and limited in their ability to verify self-attestations on new Medicaid applications in exchange for enhanced federal funding. As a result, nearly every state’s Medicaid population has grown considerably since the onset of the pandemic and nearly every Medicaid client covered by states has not been subject to a complete eligibility redetermination in at least 12 months.
Threat Monitoring Services
PCG provides a real-time population threat monitoring service which solves 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 disabled, 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