Managed Care Organizations Leverage PLEXIS’ Core Administrative Platform to Reduce Costs and Improve Quality of Care

“Evidence suggests that, compared to state-run fee-for-service, managed care can reduce overall Medicaid program costs, while providing better patient outcomes.” —Forbes

Managed care organizations (MCOs) improve the cost, utilization, and quality of managed care by leveraging PLEXIS’ trusted platform. The PLEXIS platform empowers efficient workflows including coordination for multiple capitated risk transfer arrangements, innovative network contracting arrangements, and new models of primary care coordination and disease management. With PLEXIS’ data-driven coordinated care management capabilities, payers implement efficient practice management workflows with their physician networks to create significant cost savings and better patient outcomes.

PLEXIS’ agile, scalable solution for Managed Care Organizations (MCOs) enables you to:

  • Enhance provider networks: PLEXIS’ MITA-aligned 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 State/MMIS requirements: PLEXIS’ interoperability with MMIS standards includes industry-leading configurability for flexible benefit plan administration. PLEXIS supports State Medicaid provider fee schedules, State-specific enrollment files, HEDIS data, and Medicaid recipient categories.
  • 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, the financial impacts of state regulatory changes, CMS retroactive changes, and more.
  • Manage your capitation contracts in addition to provider capitation arrangements.
  • 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.
  • 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.
  • 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 and automated claim editing.
  • 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 and helps reduce/eliminate duplication errors for an accelerated ROI.