Medical Groups Leverage the PLEXIS Platform for Accountable Care

“Payer-provider collaboration is real—and it’s reaching a new inflection point, around the opportunity for payers and providers to work together with data, for real results” –Mark Hagland, Healthcare Informatics, 2014

When it comes to patient-centric care, medical groups nationwide are leading the transition into the new era of accountable care. Collaboration between payers and providers is at an all-time high as they leverage new tools for population health management (PHM). PLEXIS provides the modern toolset to enable data-centered collaboration, electronic health record (EHR) integrations for clinical support, coordinated care, cost containment, and more.

PLEXIS provides the right tools and technology for medical groups, 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 providers 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.
  • Create significant savings: PLEXIS enables effective medical cost reduction through advanced PPO repricing, Medicare Advantage repricing, claim negotiations, and maximum network discounts (primary, wrap, and supplemental).
  • 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.
  • 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 by leveraging PLEXIS’ real-time alerts, automatic audits, health risk assessments (HRAs), responsive reporting, and more.
  • 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.