Physician Hospital Organizations Leverage the PLEXIS Platform for Success

Managed care contracting for vertically-integrated systems

Recent studies attest that vertical integration through physician-hospital alignments (PHOs) results in better care. However, the cost of improving outcomes can be unpredictable without the right technological toolset. PLEXIS provides the trusted tools for cost containment, capitated risk-sharing arrangements, proactive care management, and all aspects of managed care contracting so that you can help enhance quality of care while significantly reducing utilization costs.

PLEXIS provides the right tools and technology for Physician Hospital Organizations to achieve success, 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, data that can be utilized for Meaningful Use/Physician Quality Reporting System (PQRS) measures, 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 claims incorrectly. Payers recover significant savings and reduce utilization rates 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.

PLEXIS Healthcare Systems partners in your success

As Physician Hospital Organizations negotiate for performance-based incentives and higher quality care, PLEXIS facilitates numerous efficiencies for contracting with MCOs and managing services. PLEXIS’ core administrative platform tracks the data you need to manage delivery systems including care management, utilization management, disease management, and more.

When Physician Hospital Organizations leverage the proven effectiveness of our technological toolsets, PLEXIS typically sees these PHOs landing additional contracts with self-insured employers, with the HCFA for Medicare contracts, and with the state for managed-care Medicaid contracts.