Independent Practice Associations Successfully Leverage PLEXIS’ Core Administrative Solution

Deploying the foundation for proactive payer-provider collaboration

“Our capitation reports used to be extremely difficult and take us over two and a half days from start-to-finish. Now the PLEXIS platform finishes the entire capitation reconciliation process in only one and a half hours.”–Claims manager, Tribal Healthcare IPA

Today’s rapidly changing healthcare landscape includes new distribution models, heightened expectations for consumer engagement, new MLR drivers for administrative efficiencies, and emerging models for payer-provider collaboration. As Independent Practice Associations (IPAs) collaborate and negotiate to provide coordinated care, these organizations consistently leverage PLEXIS’ trusted platform to reduce costs and increase the value of care.

PLEXIS’ integrated clinical, financial, and administrative payer platform includes industry-leading payer-provider engagement tools, flexible contract management capabilities, powerful data aggregation for progressive risk management, an advanced toolset for cost containment, and streamlined efficiencies including provider portals for online eligibility and claim status verification, and real time claim submission and adjudication.

PLEXIS empowers IPAs to:

  • Streamline claim management with efficiencies including auto-adjudication, batch readjudication, and automated division/designation of financial responsibility (DoFR) determination during the claims adjudication process. PLEXIS supports PPO claims repricing and flexible fee schedule payment methodologies.
  • Enhance provider networks: PLEXIS automates support for network contracting/management for multiple reimbursement arrangements allowing you to enhance collaboration with providers and members.
  • Improve the cost and quality of care: With care management, UM/UR, and disease management PLEXIS gives you the full toolset for data-driven utilization review, wellness services, and value-based care.
  • Connect and communicate: PLEXIS’ real-time portals connect you to members, providers, and all essential stakeholders.
  • Automate capitation (PMPM) processing including retroactive adjustments.
  • Meet cost containment objectives: PLEXIS automates complex benefit calculations to drive high auto-adjudication rates and minimize the risk of paying claims incorrectly. IPAs recover significant savings and reduce utilization costs by leveraging PLEXIS’ configurable alerts, automatic audits, health risk assessments (HRAs), responsive reporting, and more.
  • Effectively predict costs: PLEXIS can integrate powerful business analytics (BI/BA) to enable predictive modeling and data mining to control costs and maximize health benefits by providing actionable intelligence for effective cost containment.
  • Take the worry out of regulatory compliance: The centralized core administrative hub of the PLEXIS platform enables systemic transparency for all ACA/CMS standards, including Medical Loss Ratio (MLR) reporting, ICD-10 support, and integrated, comprehensive fraud, waste, and abuse for Independent Practice Associations.