Business Process Outsourcing Administration and Risk Mitigation

At the intersection of Business Process Outsourcing (BPO) and healthcare IT enabled services (ITES), PLEXIS provides the technology stack to leverage the prime opportunities of globalization. More payers are realizing the value of implementing BPO to gain organizational flexibility and reduce costs. Whether it’s back office outsourcing, front office outsourcing, or clinical support services, PLEXIS provides the toolset to administer third-party BPO services so that you can focus on your core competencies. The PLEXIS platform mitigates common risks such as fraud, waste, and abuse (FWA) and HIPAA privacy and IT security requirements. Furthermore, it enables effective payer-provider collaboration, business intelligence, and automated efficiencies to help enhance quality of care and patient outcomes while significantly reducing utilization costs.

The PLEXIS platform streamlines administration of Business Process Outsourcing to:

  • Enhance provider networks: PLEXIS’ unified platform streamlines workflows for provider contracting and provider engagement. PLEXIS automates support for provider credentialing and provider network management for multiple reimbursement arrangements allowing you to enhance collaboration with providers and members.
  • Effectively predict costs: PLEXIS’ powerful business analytics (BI/BA) enables predictive modeling and data mining to control costs and maximize health benefits by providing actionable intelligence for effective cost containment
  • Rapidly respond to critical conditions: Payers keep costs from spiraling out of control through early identification of outliers and critical health issues. PLEXIS empowers you with configurable alerts, automatic audits, incisive health risk assessments (HRAs), and responsive reporting.
  • Enhance automation and efficiencies: PLEXIS empowers efficient fraud, waste, and abuse (FWA) detection, automated claim editing, automated calculations and processing of network fees, and efficient electronic workflows through powerful EDI solutions
  • 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 rates by leveraging PLEXIS’ real-time alerts, automatic audits, health risk assessments (HRAs), responsive reporting, and more.
  • Lower utilization rates and close care gaps with coordinated care: With integrated care management, UM/UR, and disease management, PLEXIS enables 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.
  • 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.

BPO Services

“Federal and state-level regulations are playing an increased role in healthcare payer BPO, as are measures to control fraud, waste and abuse. The result is wide windows of opportunity for BPO service providers to help payers who want to streamline operations, reduce costs, speed their time to market with new service plans, and use data analytics to reduce risk.”–Rajesh Ranjan, partner at Everest Group, 2015

PLEXIS partners with comprehensive BPO service organizations that specialize in:

  • Administrative Services: mailroom, call center, customer service, data entry, scanning, COBRA processing, electronic payments, claim routing & repricing, network management, provider contracting, clearinghouse services
  • Professional Services: plan building, plan auditing, examining, provider/member updates, enrollments, claim management consulting, custom programming
  • BPO in Africa
  • And much more