Prospective Payment Systems Features

Paying commercial claims
PPS is ideal for paying commercial in-network and out-of-network (OON) claims. With commercial OON claims—which can exceed 20 percent of the total claims that a payer receives, by volume—OptumInsight research shows that payers can realize savings of 60 percent or greater by paying OON claims using PPS.

Commercial inpatient claims easily adapt to using DRGs for non-Medicare populations, but far greater savings can be achieved by using APCs for commercial outpatient reimbursement. OptumInsight research suggests that using APCs can save Medicare Advantage payers between $300 and $450 per out-of-network claim.