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A Preferred Provider Organization (PPO) is a managed care organization in which customers use doctors, hospitals, and providers that belong to a particular network. Customers may use doctors, hospitals, and providers outside of the network for an additional cost.

Plexis Claims Manager benefit administration and claims processing software helps Preferred Provider Organizations (PPOs), Independent Physicians Associations (IPAs), and Physician Hospital Organizations (PHOs) save money by improving operational efficiencies. Plexis Claims Manager benefit administration software allows provider-based groups to increase productivity with less staff, access critical data to identify trends, and proactively track accounts receivable with capitation reports to be certain you are getting paid what you expect.

In addition to a robust benefits administration, claim processing and auto-adjudication software, healthcare PPOs, IPAs and PHOs also benefit from Plexis EDIWorks. Plexis EDIWorks eliminates a great deal of paper-based processing and improves the efficiency of electronic data interchange by integrating healthcare information directly into the Plexis Claims Manager database. EDIWorks' XML Translator allows provider-based groups to apply their own business rules to the electronic data, creating a seamless flow of information into the database.

Plexis Supports Benefits Administration Services Provided by PPOs

Enrollment -- loading members into the claim repricing system.
Claim repricing -- receipt, repricing, exporting back to the payor. Internet-based individual claim repricing programs are made available to the payor organizations, or automated EDI batch claims processing routines.
Customer Service -- taking/logging of calls from providers, plan administrators, etc.

Plexis Supports PPO Claim Processing and Benefits Administration Workflows

Premium Billing -- prospectively bill for membership on a PEPM basis.
Claim Repricing - the Plexis management fee computation rule automatically computes claim repricing during the adjudication/repricing process.
Reporting -- provides various claim savings reports to payor clients.

Optimizing Repricing Systems for Revenue Generation

Inefficiencies associated with paper claims, manual entry, and disparate repricing contracts are the key obstacles to cost-effective repricing. The use of an EDI application that integrates with a rules-based processing system's database is essential to an efficient and cost-effective repricing process. Combined with comprehensive reporting, an efficient repricing system represents a significant revenue stream for many organizations.

Efficient claim repricing software is critical to the success of many provider-based groups. For example, PPO software must include the ability to access a network's contracted discount rates. In addition, there are typically a variety of repricing contracts for different payors and networks.

A comprehensive PPO software package must collect and calculate data according to the reimbursement methods agreed upon by the PPO and TPA, health plan or self-funded group. To maximize efficiency, it is essential that any PPO claims system used for repricing and adjudication support this functionality.

Streamlined, cost-effective repricing begins with a benefits administration system that provides a seamless flow of electronic claims data from the origin of a claim to preferred provider organizations to payors. Plexis benefits administration software's automated, rules-based claim processing system allows for creating and maintaining repricing rules (including calculation of repricing fee options), which is essential for managing multiple contracts with variable discounts. Combined with Plexis EDIWorks, which seamlessly integrates with the Plexis benefits administration database, electronic health claims data can be sent directly to and from the Plexis claim processing system to auto-adjudicate claims. With Plexis claims software, PPOs can accept an electronic claim, reprice it in seconds, and return it to the payor.

Plexis claims processing system also includes two other elements required for a fully-automated, optimized PPO software repricing system. First, the repricing software must have the ability to distinguish the "billed amount" of a claim from the "allowed amount" of the claim. This repricing software functionality streamlines operations by eliminating the problem of mistaking repriced claims for duplicates. Second, the benefits administration software must include a robust reporting system that tracks and reports on all repricing activity. With the ability to distinguish a claim's "billed amount" from "allowed amount," and comprehensive reporting features, Plexis claims software serves as a powerful PPO repricing system.

Plexis Direct: Higher Auto Adjudication Rates and Faster Payments to Providers

Plexis Direct is a compact direct connectivity solution that offers provider-based groups many advantages. Plexis Direct provides universal data capture from any practice management system, a secure, automated path to web portals and ASP services, and it supports Payer edits, account ID's, knowledge-base, etc.

Plexis WEBWorks gives provider-based groups a complete web tool set to control online process, access claim and eligibility status as well as members' coverage and benefits.

Learn More About Plexis Claims Manager