Commercial PPS Methodologies

Using Ingenix solutions, payers are leveraging the established framework of Medicare’s Prospective Payment System to decrease the cost of care. This strategy enables payers to “pay as Medicare” pays, which can reduce in-network reimbursement costs by 25 percent.

Using PPS, some Ingenix customers have realized a 57 percent savings on billed charges.

Overview

Features

Reduce Risk

With PPS, health plans retain only retain the risk of underwriting health care utilization for the population of enrollees. By sharing the risk, each group is accountable for that portion of risk that they can effectively manage.

Highlights

Shift appropriate levels of risk back to providers
Reward the providers delivering effective care
Control utilization

Provider Contracting

Ingenix customers are using PPS data to reduce costs by negotiating more favorable provider contracts. Medicare inpatient (DRG-based) payment rates are typically 30 to 35 percent of charges, which gives payers the data needed to negotiate greater discounts.

An Established Methodology

Perhaps the biggest benefit is that PPS is an established methodology. Providers are familiar with using it for billing and reimbursement under DRGs for inpatient care, and APCs for outpatient care. PPS is used by many regulatory bodies, making it widely understood and accepted in the hospital community.

Questions?

To discuss how we can help your organization, please contact us:

(800) 765-6713
or engage@ingenix.com

Product Updates – Link to information related to electronic distributions, product updates and client resources.

Industry Insights –