PLEXIS Simplifies the Business of Healthcare

PLEXIS empowers diverse health plans, including medical, vision, and dental plans, enabling payers to grow and innovate across multiple business lines while maintaining a centralized platform. As new regulatory and technological drivers emerge for accountable care, adjudication modernization, and data aggregation, health plans are improving business efficiencies and member services by leveraging PLEXIS’ proven core administration and claims management platform.

The PLEXIS platform empowers health plans to:

  • Enhance provider networks: The PLEXIS platform streamlines workflows for provider contracting and engagement. PLEXIS automates support for provider credentialing and network management for multiple reimbursement arrangements allowing you to enhance collaboration with providers and members.
  • 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.
  • Lower utilization rates and close care gaps with coordinated careWith 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.
  • Model and predict costs: PLEXIS’ powerful business intelligence + business analytics (BI/BA) mines clinical and administrative data 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.
  • Configure complex benefit plans: PLEXIS created industry-leading configurability for flexible benefit plan administration (multiple products, multiple lines of business). Premium billing includes retroactive adjustments and multiple premium rate structures.
  • Create significant savings: PLEXIS enables effective medical cost reduction through advanced PPO repricing, Medicare Advantage repricing, and data that can be utilized for Meaningful Use/Physician Quality Reporting System (PQRS) measures.
  • 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 for multi-line health plans 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.
  • Manage your capitation contracts in addition to provider capitation arrangements.