Health Maintenance Organizations Optimize Managed Care

The PLEXIS platform optimizes cost containment, care management, and more

PLEXIS offers Health Maintenance Organizations (HMOs) an unbeatable toolset for managed care for multiline health plans, self-funded plans, and a diverse set of healthcare provider organizations. PLEXIS designed a flexible, scalable software architecture to accommodate numerous configurations of fee-for-service or capitated arrangements. The PLEXIS platform empowers you to meet cost containment objectives, enhance utilization review, deploy proactive care/disease management, simplify electronic workflows, and more, so that you can help enhance quality of care and patient outcomes while significantly reducing utilization costs.

PLEXIS provides the right tools and technology for HMOs, enabling you to:

  • Enhance provider networks: PLEXIS’ unified platform streamlines workflows for provider engagement. PLEXIS automates support for network management for multiple reimbursement arrangements allowing you to enhance collaboration with the designated Primary Care Physician (PCP) 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.
  • Meet cost containment objectives: PLEXIS automates complex benefit calculations to drive high auto-adjudication rates and minimize the risk of paying incorrect claims. Payers recover significant savings and reduce utilization rates by leveraging PLEXIS’ real-time alerts, automatic audits, health risk assessments (HRAs), responsive reporting, and more.
  • Simplify electronic workflows: PLEXIS’ powerful EDI hub delivers enterprise-wide efficiencies with end-to-end workflows for claims, encounter data, and more. Extensible functionality empowers payers to implement an enterprise data warehouse to track key performance metrics.
  • Automate capitation (PMPM) processing including retroactive adjustments.
  • 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, automated claim editing, and automated calculations + processing of network fees.
  • Rapidly respond to critical conditions: Payers keep costs from spiraling out of control through early identification of outliers and critical health issues. PLEXIS can integrate powerful business intelligence + business analytics (BI/BA) to deliver actionable insights.
  • 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.