Government Healthcare Program Administrators Leverage PLEXIS’ Speed-to-Value Solutions

PLEXIS deploys trusted, world-class solutions for connecting, centralizing, and empowering government healthcare payers and administrators. PLEXIS has extensive experience providing solutions for payers in spaces such as Medicare (Advantage, duals, SNP, PACE), , VHA, tribal healthcare, national health insurance programs, and municipal-based health programs. As government risk bearing organizations formulate pioneering strategies for innovative business development, PLEXIS is proud to help you deploy our proven and effective core administrative solution. Since 1996, PLEXIS has worked on some of the toughest operational challenges for these organizations. Our track record of a 95% customer retention rate reflects our experience and our capability transforming today and tomorrow’s healthcare challenges into innovative, strategic solutions for leading healthcare payers around the globe.

The PLEXIS platform empowers government healthcare program administrators to:

  • Enhance provider networks: The PLEXIS 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.
  • Simplify inpatient and outpatient prospective pricing: Real-time integration supports all Medicaid and Medicare prospective pricing methodologies with full details for defensibility and audits.
  • Model and predict costs: PLEXIS can integrate 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, CMS retroactive changes, HEDIS data, and more.
  • Manage your capitation contracts in addition to provider capitation arrangements.
  • Mass reprocessing of claims due to retroactive changes: Criteria-driven mass re-adjudication parameters allow you to identify and reprocess claims automatically, saving time, money, and eliminating errors.
  • 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 (RAPS/EDPS), 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.