Medicare Advantage Administration

PGBA offers full Business Process Outsourcing (BPO) services tailored to the needs of your Medicare Advantage business. Our full service model includes claims processing and customer service for large or small scale operations. We can also provide enrollment processing and preferred provider organization (PPO) administration.  We can be as visible or invisible as your needs require.

 

Experience -- PGBA was among the first to process PFFS claims when CMS approved Medicare Advantage options in 2002

 

Scalability -- For one client, PGBA quickly scaled systems and people when a small PFFS product grew rapidly to 9 million claims annually. In 2007, PGBA processed more than 47 million claims and with an average payment accuracy rate of 99.03%.

 

Low-cost solution for large or small business -- PGBA meets the needs of large or small-scale Medicare Advantage plans. One current client has 10,000 members while another has 261,000 members.

 

PGBA supports multiple lines of business and virtually all types of benefit designs. We constantly enhance our technology to provide cost-efficient transaction solutions for our customers.

 

PGBA's Medicare Advantage Claims Processing System

 

Our system architecture is highly cohesive so that all systems work together as one without interrupting your normal business process. The system is also loosely coupled so that automated business processes or other systems can be "snapped" into the system and uncoupled with minimal effort.

 

PGBA's claim solution options can be customized to your Medicare Advantage business model.

 

Available claims processing solutions include:

 

Flexible provider files -- demographics, credentialing, agreements, affiliations, tax identification, pricing and reimbursement arrangements.

 

Dynamic benefit files -- benefit packages, deductibles, copayments, co-insurance, benefit period maximums and lifetime maximums.

 

Integrated online, near-time claims processing -- Claims adjudication solution that incorporates electronic data interchange, adjustments, settlement, pricing, duplicate verification, reporting and customer service.

 

Interactive support systems -- Automated letter generation, electronic commerce, data warehousing, electronic data interchange, inquiry tracking, imaged/coded data and security.