Medicare Advantage Optimized for Commercial Payers
PLEXIS offers numerous workflow efficiencies to help MA plans accelerate growth. PLEXIS streamlines managed care workflows for the dually eligible, PACE programs, and numerous network management and configuration requirements. The PLEXIS platform enables payers to simplify electronic workflows, coordinate care, meet cost containment objectives, and offer cutting-edge options such as social determinants benefits packages.
PLEXIS’ agile, scalable solution for Medicare Advantage Organizations enables you to:
- Enhance provider networks: The PLEXIS platform streamlines workflows for provider engagement. PLEXIS automates support for network management for multiple reimbursement arrangements allowing you to enhance collaboration with providers and members.
- Configure complex benefit plans: PLEXIS created industry-leading configurability for flexible benefit plan administration (multiple products, multiple lines of business). Premium billing includes retroactive adjustments and multiple premium rate structures.
- Lower utilization rates and close care gaps with coordinated care: PLEXIS can integrate care management, UM/UR, and disease management to enable powerful, preventative, outcome-based wellness. We include capabilities for medical management negotiations, data-driven utilization review, wellness services, and monitoring/management of high-dollar claims.
- Model and predict costs: PLEXIS can integrate powerful business intelligence + business analytics (BI/BA) to deliver actionable insights. Predict outcomes and reduce risk as PLEXIS’ BI models the effects of different reimbursement configurations, CMS retroactive changes, HEDIS data, and more.
- Simplify Medicare Prospective Pricing: Simplify pricing by embedding it within the adjudication process to deliver better accuracy with real-time results.
- Manage your capitation contracts in addition to provider capitation arrangements. Offer value-based care with direct contracting models or other capitated options.
- Meet cost containment objectives: PLEXIS automates complex benefit calculations to drive high auto-adjudication rates and minimize the risk of paying claims incorrectly. Payers recover significant savings and reduce utilization by leveraging PLEXIS’ real-time alerts, automatic audits, responsive reporting, and more.
- Simplify electronic workflows: PLEXIS’ powerful EDI hub delivers enterprise-wide efficiencies with end-to-end workflows for claims, encounter data (RAPS/EDPS), and more. Extensible functionality empowers payers to implement an enterprise data warehouse to track key performance metrics.
- Connect and communicate: PLEXIS’ real-time portals connect you to members, providers, and all essential stakeholders. With PLEXIS’ self-service healthcare portal, members securely access eligibility, provider information, ID cards, claims history, and other configurable data fields – all from their computer, tablet, or smartphone.
- Enhance automation and efficiencies: PLEXIS empowers efficient fraud, waste, and abuse (FWA) detection and automated claim editing.
- Enhance transparency for evolving compliance requirements: Accelerate growth for multi-line health plans while minimizing risk through end-to-end transparency and centralized premium and claim data. PLEXIS provides holistic visibility for health plans. Meet compliance requirements and helps reduce/eliminate duplication errors for an accelerated ROI.
PLEXIS helps simplify Medicare plan administration with:
- Configurable Late Payment Interest functionality
- Membership and Premium reconciliations
- Integrated comprehensive fraud waste and abuse with grievances and appeals
- Capitation and billing prorated based upon Medicare Rate Cells and categories, including Nursing Home Certified, Working Aged, and hospice
- Automated CMS-certified correspondence, including ID cards, and multiple languages/fonts
