PLEXIS Simplifies the Business of Healthcare

PLEXIS empowers diverse health plans, such as Medicare Advantage, managed Medicaid, and commercial to manage multiple lines of business including medical, vision, and dental products, enabling payers to grow and innovate across these lines while maintaining a centralized platform. As new regulatory and technological drivers emerge for accountable care, adjudication modernization – including value-based reimbursement, data aggregation, and interoperability. Health plans are improving business efficiencies and member services by leveraging PLEXIS’ proven core administration and claims management platform.

The PLEXIS platform empowers diverse health plans 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.
  • 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.
  • 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.
  • Configure complex benefit plans and reimbursement arrangements: 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.
  • Create significant savings: PLEXIS enables effective medical cost reduction through advanced PPO repricing and Medicare Advantage repricing.
  • 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. Recent reports continue to indicate immense savings from electronic solutions.*
  • Connect and communicate: PLEXIS’ portals apps 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 compliance requirements and helps reduce/eliminate duplication errors for an accelerated ROI.
  • Manage your capitation contracts in addition to provider capitation arrangements.

*According to the CAQH Index Report, “health plans pay, on average, an additional $3 for every manual transaction they must support vs. what it would cost them to support this same transaction electronically.”