Medicare Advantage Optimized for Commercial Payers

The 2016 Medicare Advantage (MA) Star Ratings demonstrate a steady improvement in the number of high-performing plans as patients receive better care and payers benefit from MA quality bonus payments. PLEXIS offers numerous workflow efficiencies for MA plans. PLEXIS streamlines managed care workflows for the dually eligible and numerous network management and configuration requirements. The PLEXIS platform enables payers to simplify electronic workflows, coordinate care, meet cost containment objectives, and more.

PLEXIS’ agile, scalable solution for Medicare Advantage Organizations (MAOs) 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.
  • Model and predict costs: PLEXIS can integrate powerful 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.
  • Simplify Medicare Prospective PricingSimplify pricing by embedding it within the adjudication process to deliver better accuracy with real-time results.
  • 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.
  • Manage your capitation contracts in addition to provider capitation arrangements.
  • 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 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 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.