Jay Hammond

Director of Sales

Dual eligibles, no problem

Dual Eligibility

For over a decade, PLEXIS has deployed streamlined functionality to simplify adjudication for Medicare/Medicaid duals

There has been a lot of recent publicity and discussion about dual eligibles, and for good reason, as we will see shortly. PLEXIS’ guiding mission is to create positive and meaningful change within the healthcare industry, so over ten years ago we deployed the functionality to coordinate payer administration of Medicare/Medicaid dual eligibility claims. While some competing vendors are still seeking to create this functionality, PLEXIS continues to simplify the adjudication process for dual eligibles so that payers can reap the benefit of greater revenue from greater claim accuracy.

So who are the dual eligibles?

Over 9 million seniors or disabled Americans are eligible for both Medicare and Medicaid. Historically this population of dual eligibles has encountered discontinuity of care because of the disparities among payment delivery models between various state Medicaid programs and the federal Medicare program. Furthermore, even though dual eligibles comprised 15 percent of the 2008 Medicaid enrollment, they accounted for 39 percent of spending.1 The Affordable Care Act (ACA) is continuing to work to improve the coordination and delivery of consistent and cost-effective care for the dually eligible. CMS is currently funding about a dozen state pilot programs, or Financial Alignment Demonstrations (FADs), to test various models of capitation and customer care.

Coordinating consistent, cost-effective care

With over 19 years of marketplace experience, PLEXIS provides the keystone toolset to coordinate dual eligibility payment processing consistently throughout a variety of different state programs’ disparate billing systems. We understand that no single FAD solution will apply to every state, so our architects constructed the PLEXIS platform with Service-oriented Architecture (SOA) so it can maintain the agility to meet evolving payer and legislative models. During the adjudication process, the PLEXIS solution identifies members with dual eligibility, processes claims separately for Medicare and Medicaid, and greatly increases payers’ administrative efficiency through a single-pass, simplified adjudication process.

Dual eligibles will continue to garner a great deal of discussion as legislators and payers seek to meet their long-term care needs while lowering costs associated with high-risk members. PLEXIS is proud to continue collaborating with payers and providers to coordinate more effective care in compliance with CMS initiatives. From EDPS claims data through the administration of evolving provider network agreements, PLEXIS has you covered.

1 According to “A Brief Survey of Dual Eligibles and the ACA,” by Rebecca A. Owen of the Society of Actuaries (2013).


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