Preferred Provider Organizations Leverage the PLEXIS Platform for Success

PLEXIS provides the trusted tools for capitated risk-sharing arrangements, cost containment, and proactive care management so that you can help enhance quality of care while significantly reducing utilization costs.

PLEXIS provides the right tools and technology for Preferred Provider Organizations to achieve success, enabling you to:

  • Enhance provider networks: PLEXIS’ unified 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.
  • Lower utilization rates and close care gaps with coordinated care: PLEXIS can integrate care management and UM/UR 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.
  • Create significant savings: PLEXIS enables effective medical cost reduction through advanced PPO repricing, Medicare Advantage repricing, and maximum network discounts (primary, wrap, and supplemental).
  • 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, health risk assessments (HRAs), responsive reporting, and more.
  • Automate capitation (PMPM) processing including retroactive adjustments.
  • Simplify electronic workflows: PLEXIS’ powerful EDI hub delivers enterprise-wide efficiencies with end-to-end workflows for claims, encounter data, 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, automated claim editing, and automated calculations + processing of network fees.
  • Rapidly respond to critical conditions: Payers keep costs from spiraling out of control through early identification of outliers and critical health issues. PLEXIS can integrate powerful business intelligence + business analytics (BI/BA) to deliver actionable insights.
  • Enhance transparency for evolving compliance requirements: Accelerate growth while minimizing risk through end-to-end transparency and centralized premium and claim data. PLEXIS provides holistic visibility for compliance requirements.

PLEXIS Healthcare Systems partners in your success

As PPOs negotiate for performance-based incentives and higher quality care, PLEXIS facilitates numerous efficiencies for contracting with MCOs and managing services. PLEXIS’ core administrative platform tracks the data you need to manage delivery systems including care management, utilization management, and more.