Plexis Benefit Administration Software for Health Insurance Companies

Plexis benefit administration software provides health insurance companies with a claims system that reduces costs by focusing on health plan results instead of health plan claims processing. Administrative costs are reduced when premium billing, capitation, commissions, and claim adjudication are automated and staff resources can study trends and actual expenses to make smart decisions. Plexis health plan administration software includes standard and ad-hoc reporting capabilities that provide decision-making information for every area of health plan management.

Plexis claims systems provide health plan administrators plan with reports summarizing who's making the claims, comparing provider costs, and what services members are choosing to use. From managing member enrollment and providing information instantly to call centers, to adjudicating claims in seconds and administering contracts in key strokes, health insurance companies will accomplish more in less time with Plexis benefits administration software.

Plexis benefit administration and claim processing software provide the flexibility to re-configure the system as changes in markets, products or regulations develop. As new insurance products, such as consumer-directed healthcare (CDHC) plans, emerge in the marketplace, Plexis rules-based processing engine makes it easy to change business rules without hiring a team of programmers.

Plexis healthcare ASP and BPO services allow health insurance companies to automate benefits administration and claim processing without making major investments in additional hardware or IT personnel.

Health insurance claim processing also benefits from Plexis EDIWorks. EDIWorks is electronic data interchange (EDI) healthcare software that eliminates a great deal of paper-based processing and improves claim processing efficiency by integrating claims adjudication data from providers directly into the Plexis Claims Manager database. The EDIWorks XML Translator allows heath plan administrators to apply their own business rules to the electronic data, creating a seamless flow of information into the database.

Plexis WEBWorks is user-configurable healthcare web portal software that significantly reduces health plan claims processing costs associated with call center operations. Plexis WEBWorks allows providers to check members' eligibility status online and provides a full-service healthcare web portal that allows consumers to check claim status, research provider network information, enroll on-line, and review health links that can educate consumers about medical issues and improve their well being.

Plexis benefits administration software streamlines the essential elements of health insurance claims processing:

• Premium billing -- to the employer or individuals.
• Capitation -- pay cap to IPAs/medical groups for various populations in specific geographic regions, where a managed care plan is offered.
• Commission processing/payment -- to agents and brokers that bring groups/individuals to the insurance company; may be internal sales staff or external agents.
• Enrollment -- loading employees and their dependents into the benefit/claim system, generating ID cards, sending out letters [approved, denied coverage, etc.], benefit booklets, provider directories, etc.
• Claim processing -- receipt, repricing, settlement, payment, timely payment penalties, etc.
• Customer Service -- taking/logging of calls from members, providers, plan administrators, etc.
• Case Management -- for insurance companies that are MCOs - medical management, UM/UR services aimed at managing the care of the employees and their dependents in an effort to keep utilizations expenses down; often billed to the employer group on a PEPM basis.
• PPO Brokering/Negotiation -- bring PPOs and employer groups together, will provide out-of-network fee negotiation with other PPOs.
• Excess Loss/Stop-Loss coordination -- report to and coordinate with excess loss carriers for claims that exceed the pre-determined monthly shock-loss" (individual claim) or "stop-loss" (group) amount).
• Underwriting -- assesses the risk of enrolling an individual or group; guarantees the services provided by the purchase of the insurance.
• Actuarial Review - ongoing [quarterly and/or annually] review of claims experience/medical loss ratio [premium income to claims expense] to determine if rates are too low/high, what populations are costing the most money, what groups/individuals will be allowed to be renewed and which will not, etc.
• "Earned" vs. "Unearned" Premium Tracking -- tracking of premium amounts collected vs. the time period remaining for the coverage of that premium. This is very important for coverage periods greater than one month [i.e., quarterly, semi-annual and annual].
• Quoting/Renewals -- provide quotes to new prospects and perform policy renewals for existing groups/individuals.
• Consumer Directed Healthcare ("CDHC") - a very big focus of insurance companies, and they are now offering much more "consumer" choice in the products that they offer (this is where Quantum Choice will offer superior functionality and flexibility)
• ASO/TPA Services (provide additional HR type administrative services for self-funded employer groups, such as COBRA, flex, STD/LTD, etc.).

Unique Workflows

Some workflows that are typical (and unique) to most health insurance companies include, but are not limited to:

• Use of PPOs for repricing of claims (often insurance companies will not have access to, or will not load an external PPO's fee schedule(s) in their claim system, so claims are sent off to the PPO for repricing (use of PCM's "Allowed Amount" functionality)
• For managed care plans, will contract with IPAs/medical groups who will take on risk for certain services (usually all professional, specialist, outpatient and pharmacy services). Therefore, the insurance company will pay capitation to the IPA/medical group (use of PCM's capitation functionality - "All Members with Benefit Contract" method)
• When not working with a PPO, will often use the UCR and % of Medicare Allowable payment methodology for pricing claims, as direct provider agreements may not exist, so UCR is a contracting standard in place that both sides (insurance company and provider/provider network) can agree upon (i.e., 85th percentile of UCR; use of PCM's UCR fee schedule payment method functionality)
• Will work with and external pharmacy benefit manager ("PBM"), which is a TPA that administers RX benefits and claim payments; the TPA will receive encounter data back from the PBM for internal operational reporting as well as to share with the employer (use of PCM's "univclaim" tables to store this data)
• Will need to be able to provide various stop-loss/shock-loss reports to management and to the excess loss carrier (use of PCM's stop-loss report, need to provide clients with more reports however, which WEBWorks does a very good job of)
• For those insurance companies that provide ASO/TPA services, they serve as an extension of the HR department at the employer group, so they will often provide additional services in the realm of employee benefit administration such as claim processing, COBRA administration, short-term disability ("STD"), long-term disability ("LTD"), workers compensation, Section-125 (cafeteria plan)/flexible spending account ("Flex"), Health reimbursement accounts ("HRA") and health savings accounts ("HAS"); therefore the insurance company providing ASO/TPA services would prefer one single administration system that can handle all of these administrative functions.

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