Medicare Workflows Optimized for Cost Savings and Patient Outcomes

As CMS works to shift Medicare reimbursement toward value-based payments such as bundled payments and APMs, payers are responding with innovative risk-sharing arrangements. PLEXIS architects created the fundamental interoperability to serve any model of capitated or fee-for-service (FFS) reimbursement. PLEXIS software enables you to streamline your workflows for adminstration of many different types of programs and reimbursement methodologies. The PLEXIS platform enables payers to simplify electronic workflows, coordinate care, meet cost containment objectives, and more.

PLEXIS’ agile, scalable solution for Medicare enables you 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 carePLEXIS 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 pricingReal-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.

Medicare administration simplified with PLEXIS’ solution set:

  • CMS Data Loader
  • CMS Assistant Surgeon Rules on the payment contract
  • Automated Beneficiary Enrollment
  • Flexible fee schedule payment methodologies supported
  • Configurable procedure code depreciation functionality
  • Configurable Late Payment Interest functionality
  • Membership and Premium reconciliations
  • Integrated comprehensive fraud waste and abuse
  • Capitation and billing prorated based upon Medicare Rate Cells and categories, including Nursing Home Certified, Working Aged, and hospice
  • Automated CMS-certified correspondence, including ID cards, and multiple languages/fonts

See our solution for Medicare Advantage