Management Services Organizations Achieve Success with PLEXIS

Bridging the gap between FFS and value-based care

“Encouraging providers and payers to collaborate is top of mind for me these days. As a practicing physician and a vocal advocate of improving care through population health management (PHM), I’m acutely aware of the benefits collaborating with payers can bring–and has already brought–to my patients, my practice and those of many of my peers.” –Dr. Paul Taylor, HealthData Management, 2014

Management Services Organizations (MSOs) are forging new pathways into outcome-based reimbursement models to incentivize better population health management. PLEXIS understands the complexities of implementing effective risk-based payment models, so we created a flexible software architecture to accommodate numerous configurations of fee-for-service or capitated arrangements. The PLEXIS platform empowers you to enhance collaborative provider networks, meet cost containment objectives, 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 MSOs, enabling you to:

  • Enhance provider networks: PLEXIS’ unified platform streamlines workflows for provider contracting and provider engagement. PLEXIS automates support for provider credentialing and 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: With 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.
  • Create significant savings: PLEXIS enables effective medical cost reduction through advanced PPO repricing, Medicare Advantage repricing, claim negotiations, and maximum network discounts (primary, wrap, and supplemental).
  • Meet cost containment objectives: PLEXIS automates complex benefit calculations to drive high auto-adjudication rates and minimize the risk of paying incorrect claims. Payers recover significant savings and reduce utilization costs by leveraging PLEXIS’ real-time alerts, automatic audits, health risk assessments (HRAs), responsive reporting, and more.
  • Automate capitation (PMPM) processing including retroactive adjustments.
  • Simplify electronic workflows: PLEXIS’ powerful EDI hub delivers enterprise-wide efficiencies with end-to-end workflows for claims, encounter data, 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, automated claim editing, and automated calculations + processing of network fees.
  • Rapidly respond to critical conditions: Payers keep costs from spiraling out of control through early identification of outliers and critical health issues. PLEXIS’ powerful business intelligence + business analytics (BI/BA) mines clinical and administrative data to deliver actionable insights.
  • 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.