Powerful, Cost-effective Solutions for Veterans Health Administration

As new legislation expands care for veterans, effective administration and operation of Veterans Health Administration (VHA) healthcare becomes increasingly critical even as payers are faced with greater challenges and competition. Leading VHA payers are leveraging the renowned speed-to-value of PLEXIS’ solutions to capitalize on growth opportunities.

  • In my 23 years in claims adjudication, I have never worked on a claim system where the plan setup is as easy, efficient and as straightforward as PLEXIS.

    Associate Director

    Veterans Administration Financial Services

The unified PLEXIS platform automates payer processes and empowers greater business efficiencies. With two decades of experience implementing and supporting VHA payers, the PLEXIS team of subject matter experts has unmatched experience and support capabilities.

The PLEXIS platform empowers VHA payers 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.
  • 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.
  • Simplify inpatient and outpatient prospective pricing: Real-time integration supports all Medicaid and Medicare prospective pricing methodologies with full details for defensibility and audits.
  • Model and predict costs: PLEXIS can integrate 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.
  • Manage your capitation contracts in addition to provider capitation arrangements.
  • Mass reprocessing of claims due to retroactive changes: Criteria-driven mass re-adjudication parameters allow you to identify and reprocess claims automatically, saving time, money, and eliminating errors.
  • 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 costs 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 while minimizing risk through end-to-end transparency and centralized premium and claim data. PLEXIS provides holistic visibility for compliance requirements and helps reduce/eliminate duplication errors for an accelerated ROI.