Payer-Provider Collaboration, Simplified
Drive better population health outcomes by enhancing engagement and transparency
Today’s payers understand the importance of enhanced engagement and collaboration with providers in order to facilitate the business and financial relationships that improve population health outcomes. Value-based care organizations are at the forefront of the future of healthcare as they take on risk to engineer tomorrow’s successful models for payer-provider collaboration.
PLEXIS architected the right toolset to empower you to enhance provider networks, meet cost containment objectives, integrate reference-based pricing, deploy proactive care management, simplify electronic workflows, and more, so that you can help enhance quality of care and patient outcomes while significantly reducing utilization costs.
PLEXIS provides the right tools and technology for outstanding payer-provider collaboration, enabling you to:
- Enhance provider networks: PLEXIS’ unified platform enhances provider engagement. PLEXIS automates support for network management for multiple reimbursement arrangements allowing you to improve 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.
- Create significant savings: PLEXIS enables effective medical cost reduction through advanced PPO repricing, Medicare and Medicaid pricing, and maximum network discounts.
- 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 and responsive reporting. PLEXIS empowers efficient fraud, waste, and abuse (FWA) detection, automated claim editing, authorizations, and automated calculations + processing of network fees.
- Connect and communicate: Real-time portals connect you to members, providers, and all essential stakeholders. PLEXIS provides essential connectivity to integrate a multitude of portal solutions. Additionally, PLEXIS WEBworks is a self-service healthcare portal that allows members to securely access eligibility, provider information, ID cards, claims history, and other configurable data fields – all from their computer, tablet, or smartphone. PLEXIS offers multiples solutions to achieve real-time adjudication (RTA) of claims submission and adjudication.
- Simplify electronic workflows: PLEXIS’ powerful EDI hub and web-service based APIs deliver enterprise-wide efficiencies with end-to-end workflows for provider, claims, encounter data, and more. PLEXIS also offers the ability to integrate with leading provider data management (PDM) solutions.
- Enhance automation and efficiencies: The PLEXIS platform conducts real-time callouts to claim pricing and editing sources. It also provides automated, event-based notifications to providers, members, and operation staff. PLEXIS’ Orion user interface offers additional cost-saving advantages such as claim inventory management and queuing.
- Rapidly respond to critical conditions: Payers keep costs from spiraling out of control through early identification of outliers and critical health issues such as claims lag, task management, and claims inventory management. PLEXIS can integrate powerful business intelligence + business analytics (BI/BA) to deliver actionable insight.
- Automate capitation (PMPM) processing: PLEXIS includes automated retroactive processing and enables capitation reimbursement according to configurable factors.
- Meet evolving compliance requirements: PLEXIS helps you ensure timely payment of claims to meet compliance with your provider and network contracts. Other compliance-oriented solutions include claims inventory management, reimbursement automation, and flexibility in contract administration.
PLEXIS Healthcare Systems partners in your success
ACOs, IPAs, PHOs, MSOs, PPOs, HMOs, and other value-based organizations understand the importance of collaboration, and PLEXIS has a reputation for collaborating in your success. We understand that you need an end-to-end solution to influence providers to ensure timely, value-based care, and at the same time you need to influence patients to make informed, responsible decisions about their healthcare.
For the past 20 years, PLEXIS has specialized in empowering payers with proactive tools for centralizing data intelligence and creating effective channels for transparency and provider/member engagement. Collaboration isn’t possible without the right information at the right time. For example, if you want to create an incentive for providers to follow a preventive protocol, then you must be able to give them information on what the new protocol is, which patients it applies to, and how it influences their compensation.
In order to administer a high level of performance without increasing the administrative burden, payers must leverage a centralized technology platform. PLEXIS streamlines the movement toward value-based reimbursement by ensuring your entire business ecosystem is connected and your business processes are agile, transparent, and informed by the centralized data intelligence that the PLEXIS payer platform provides.