The Comprehensive Solution to Enhance and Optimize Business Operations in Managed Care Organizations
Quantum Choice, the cutting-edge platform from PLEXIS Healthcare Systems, is engineered to transform the way Managed Care Organizations and PACE plans operate, ensuring that healthcare payer administrators can focus on what matters most — providing outstanding care to their clients and being as operationally efficient as possible.
Comprehensive Provider Data Management
Quantum Choice stands out with its robust provider data management capabilities, adept at tracking providers, managing corresponding vendor, practice office, and network affiliation details. This includes direct contract administration and fee schedule management, enabling many different reimbursement methodologies (Medicare, Medicaid, other) – including different reimbursement methods for the same provider based on different conditions.
Capitation : Revenue Reconciliation, Provider Payments
Revenue Reconciliation:
Harness the power of Quantum Choice’s advanced capitation reconciliation capability. Quantum Choice enables finance departments to reconcile the revenue amount received from the respective government entity (Medicare, Medicaid) with the amount expected to be received for each eligible plan member, ensuring awareness of potential financial risk.
Provider Capitation Payments:
Quantum Choice enables health plans to capitate and provide prospective payments to providers based on eligible members assigned to those providers, fostering financial clarity and efficiency.
Seamless Integration
Easily integrate your Electronic Health Record (EHR) system with Quantum Choice, providing a unified and streamlined ecosystem for key healthcare data records and transactions. This integration ensures that information flows smoothly between systems, minimizing errors and enhancing patient care quality. For example, if the EHR is the system of record/source of truth for member/eligibility and/or referral data, the EHR can automatically feed this data to Quantum Choice via web service calls to ensure this data is loaded within the core administrative system prior to receipt of a claim.
Automated Claim Processing
Quantum Choice enables auto-adjudication of claims, including use of EDI for automated receipt and loading of claims, and supports real time application of Medicare edits and pricing. Once claims are processed and paid, plans have to perform specific claim encounter reporting to CMS (Medicare) and potentially the state (Medicaid) as well. Quantum Choice provides X12 837 claim encounter file extract processing, which are submitted to our
partner’s Encounter Reporting Process portal which is tailored for both state (Medicaid) and federal (CMS) requirements. The combination of auto-adjudication of claims followed by a structured encounter reporting process speeds up the claim handling process while maintaining precision and compliance with government health plan administrative requirements.
The PLEXIS platform empowers PACE organizations 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.
