Who is FAIR Health?
Why was FAIR Health formed?
FAIR Health was founded in 2009 after then-New York State Attorney General Andrew Cuomo uncovered potential conflicts of interest in the methods that health insurers were using to determine reimbursements to patients who received care from providers outside their health plans’ networks. The Office of the Attorney General reached settlement agreements with health insurance companies that do business in New York State; those agreements focused on bringing fairness and transparency to the out-of-network reimbursement system.
FAIR Health was established as part of this settlement. Our mandate was to create and maintain a new database of charge data for healthcare procedures, to offer consumers tools to make it easier for them to estimate out-of-network expenses and to make our data available for academic research.
While the investigation took place in New York, the settlement had national implications. Since our inception, FAIR Health has established a national reputation for bringing cost transparency to the healthcare sector; FAIR Health data currently power a range of data tools that are used by healthcare stakeholders across the nation.
How was the FAIR Health claims database created?
In January 2009, then-New York Attorney General Andrew Cuomo announced the settlement of an investigation into the method used by certain health insurers to determine reimbursements for patients who receive care from out-of-network providers. The settlement agreement reached with 12 health insurers focused on bringing fairness and transparency to the out-of-network reimbursement system by creating a non-industry, independent repository of claims data that would be overseen by a nonprofit organization. FAIR Health was formed to establish that database and oversee the ongoing contribution of claims data to it. The FAIR Health database currently includes claims data from over 60 payors nationwide and covers 2002 to the present.
What is the purpose of FAIR Health and how is it unique?
FAIR Health is committed to promoting transparency in healthcare costs and health insurance information through comprehensive data products, custom analytics, interactive data visualizations and consumer resources. As an independent, unbiased source of healthcare cost information, FAIR Health is the trusted data provider to a wide range of customers including but not limited to payors, healthcare professionals, government agencies, unions, consultants, pharmaceutical companies, employers, consumers and researchers.
Who advises the work of FAIR Health?
Who does FAIR Health serve?
FAIR Health serves a broad range of healthcare stakeholders, among them:
• Commercial audiences (e.g., payors, third-party administrators, pharmaceutical companies, medical equipment companies, litigation
support advisors and benefit consultants)
• Healthcare consumers
• Government agencies
• Researchers and universities
• Healthcare professionals and facilities
• Unions and collectively bargained groups
• Public and private health insurance exchanges
How are FAIR Health data used?
Stakeholders use FAIR Health data in a great variety of ways. Some examples include:
• Out-of-network (UCR) fee schedule development
• Reference point for legislated consumer protections and state health programs
• In-network fee schedule development
• Workers’ compensation and auto liability program fee schedule development
• Claims adjudication
• Cost transparency tools
• Public and private exchange plan selection and management
• Employee and member education
• Reimbursement risk management
• Network design and provider recruitment and negotiations
• Provider fee schedule evaluation
• In-network and out-of-network cost comparisons
• Healthcare cost projections
• Market research
• Sales and inventory planning
• Litigation support
• Research and policy development
• All Payer Claims Database (APCD) and Centers for Medicare and Medicaid Services (CMS) Data Center development and maintenance
• Government fee schedule development
Visit Data Solutions to learn how your organization can use FAIR Health data.
How do I stay up-to-date with FAIR Health news?
Where does FAIR Health obtain its claims data?
FAIR Health obtains our data from more than 60 health plans, insurance carriers and third-party administrators (TPAs) who contribute claims data through the FAIR Health Data Contribution Program described below.
What is in the FAIR Health data repository?
The FAIR Health data repository is made up of de-identified data from billions of privately billed claims for medical and dental services submitted by healthcare professionals to health insurers across the nation. The database includes over 23 billion billed procedures, from 2002 to the present. The database grows continuously as new data are received each month; we receive approximately a billion new claims each year. The data are submitted to FAIR Health by healthcare payors that collectively insure over 150 million individuals in the private (i.e., non-government sponsored) healthcare system. In addition to the privately billed claims, FAIR Health’s repository contains approximately three billion claims received from CMS.
How do you protect the privacy of patients, providers and data contributors?
FAIR Health places the highest priority on the security of our contributors’ data. We apply rigorous protocols to de-identify all personally identifiable patient information, in accordance with the Health Insurance Portability and Accountability Act (HIPAA) “safe harbor” rule and other requirements. We also exclude from our data products any personal information that could identify a specific patient, provider, plan or contributor.
Who maintains the data?
FAIR Health owns and manages the database and works with advisors from the academic and research community to refine the statistical methodologies and algorithms that are employed to develop and enhance the value of our products.
Who helps FAIR Health analyze and organize the claims data that it collects?
FAIR Health’s expert staff works with a team of research universities known as the Upstate Health Research Network (UHRN) to examine the data and recommend the statistical methods by which FAIR Health develops its data tools. This team includes some of the most respected experts in healthcare policy, medicine, economics and statistics from academic institutions across the country and is led by Syracuse University and Cornell University.
How are the data in the FAIR Health database validated?
FAIR Health applies rigorous quality assurance processes to validate data before they are accepted by the FAIR Health Data Contribution Program and added to our repository. Each data submission undergoes a series of thorough edit checks by in-house experts in statistics, mathematics and information technology to help prevent flawed data from being included. Part of this process involves testing the data with statistical algorithms to ensure that invalid entries are eliminated. For example, FAIR Health identifies and quarantines claims data with invalid dates of service and/or invalid ZIP Codes. If data fail to pass the edit checks, FAIR Health will contact the data contributor to address the source of errors or concerns.
How does FAIR Health make its data available?
FAIR Health makes its data available in a range of formats to a variety of stakeholder groups. We offer standard data products, custom analytics, the FH Fee Estimator® for Healthcare Professionals, consumer engagement tools and datasets for academic research that are made available through its Research Support Program. FAIR Health also offers a separate website for consumers at www.fairhealthconsumer.org (consumidor.fairhealth.org in Spanish.) You can learn more by visiting the Data Solutions section.
How does FAIR Health handle outliers that may represent invalid charges?
FAIR Health employs a proprietary extreme outlier methodology to detect and remove data entries that represent invalid charge data.
How does FAIR Health handle small cells/low frequency data?
To address small cells (i.e., procedures performed at a very low frequency in a particular geographic area), FAIR Health employs Relative Value Methodology. Click here to learn more.
What geographic areas are reflected in the FAIR Health database?
The FAIR Health database includes billed charges from all geographic areas in the United States and its territories, including all 50 states; Washington, DC; Puerto Rico and the US Virgin Islands. FAIR Health’s repository does not include billed charges from outside the United States.
How frequently are data in the products refreshed?
FAIR Health data products are updated at least twice yearly to reflect new data collected and included in the FAIR Health claims database. Product modules include 12 months of data that are updated for each release. The cutoff date for data to be included in a module is three months prior to the release date.
Does FAIR Health set usual and customary rates for insurers?
No. FAIR Health offers benchmark data to assist insurers in establishing usual and customary rates (UCR) for out-of-network reimbursement. FAIR Health does not set UCR rates or out-of-network reimbursement amounts; those determinations are made by insurers themselves. FAIR Health data are intended to inform those decisions.
What types of custom analytics are available?
What is the FAIR Health Data Contribution Program?
Our clients rely on the FAIR Health database to provide a rich array of geographically specific benchmark data. The claims data that FAIR Health receives are contributed by payors through the FAIR Health Data Contribution Program. Contributors receive credits against their license fees for FAIR Health data products as well as other incentives. In addition, by contributing their data, these organizations ensure that their claims experience is represented in the tools that FAIR Health offers the industry. A large data pool makes FAIR Health data products truly representative of the private insurance market and enables FAIR Health to develop new data products to serve the healthcare industry and its many stakeholders.
Who can submit data?
For the reasons stated below, participation in the FAIR Health data contribution program is limited to the following types of organizations, provided that they are current licensees of FAIR Health data products:
• Health plans
• Insurance carriers
• Third-party administrators
FAIR Health regrets that it cannot accept claims submissions from healthcare practitioners, due to the high probability that provider claims will not be unique and will result in the duplication of data within the database.
To learn more about the value of participating in our data contribution program, contact FH Support by e-mail at email@example.com or call 855-301-3247, Monday through Friday, 9:00 a.m. to 6:00 p.m. Eastern Time. You also may visit the Become a Contributor section.
How do I submit data files to FAIR Health?
After you sign up as a contributor, the FAIR Health data team will work closely with you to establish and test the file transfer protocols in order to get your organization’s data contribution up and running quickly and easily according to contribution guidelines. We also will monitor your contribution feeds and provide guidance as needed. For more information, visit How to Submit Data.
What incentives are there for submitting data to FAIR Health?
FAIR Health offers credits that reduce data licensing fees to qualified data contributors. Data credits will offset licensing fees for the next renewal term after the data are accepted by FAIR Health.
Participants in the data contribution program can earn credits of up to 50 percent of licensing fees for each product renewal term beginning after the data are accepted into the program. Credits are based on the number of accepted claims and vary depending on the type of data provided. Data contributors are also eligible to choose from certain complimentary data reports that offer valuable market insights. To learn more, contact FH Support by e-mail at firstname.lastname@example.org or call 855-301-3247, Monday through Friday, 9:00 a.m. to 6:00 p.m. Eastern Time.
Does FAIR Health provide training for contributing data?
Yes, FAIR Health provides all contributors with telephone-based training for the initial set-up and ongoing data submission process.
What assistance does FAIR Health offer to clients?