Solutions for Medicare, Medicaid, and Medicare Advantage
Dual eligibles, no problem
PLEXIS reduces payers’ costs while coordinating dual eligibility payment processing
“Medicare, Medicaid, Dual Eligibles and the Health Benefits Exchanges now account for a majority of most health plans’ revenue and earnings. With this shift in financing come new core capabilities all payers and their provider partners must have to thrive in the next 5 years. ” —AHIP, 2015
PLEXIS empowers payers to coordinate optimum healthcare delivery and payment for the growing population of over 9 million dual eligible beneficiaries with complex and costly healthcare needs. PLEXIS provides the proven toolset to reduce payers’ costs, optimize enterprise-wide operational efficiencies, enhance provider networks, and coordinate complex care needs with advanced care management.
With PLEXIS’ solution for dual eligibles, payers are empowered to:
Improve the cost and quality of care: PLEXIS can integrate care management, UM/UR, and disease management to give you the full toolset for data-driven utilization review, Wellness services, and value-based care.
Configure complex benefit plans: PLEXIS’ industry-leading configurability for flexible benefit plan administration (multiple product, multiple line of business support) includes COB provisions for dual eligibles’ complex benefit plans.
Enhance provider networks: PLEXIS automates support for network management for multiple reimbursement arrangements allowing you to enhance collaboration with providers and members.
Reduce administrative costs: Automate and simplify adjudication, administration, and cost containment measures for Medicare Advantage, managed Medicaid, and dual eligibles. The PLEXIS platform processes claims for both Medicare and Medicaid within the same claim, greatly increasing administrative efficiency through a single-pass, simplified adjudication process.
Reduce or eliminate manual processes: PLEXIS’ HIPAA-ready X-12 5010 EDI hub provides end-to-end processing of encounter data and all electronic workflows.
Support multiple models of care delivery: Our rules-based engine supports both the capitated model and the managed FFS model for CMS’ Financial Alignment Initiative. Automated capitation (PMPM) processing includes retroactive adjustments.
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.
Historic challenges with high costs and discontinuity of care
“Dual eligible beneficiaries alone account for almost 40% of all [Medicaid] spending, driven largely by spending for long-term care. The 5% of Medicaid beneficiaries with the highest costs drive more than half of all Medicaid spending.” –KFF report, Medicaid Moving Forward, 2015.
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. As the Kaiser Family Foundation report illustrates, dual eligibles account for a disproportionate amount of spending.