FAIR Health Data Can Inform Medicaid Programs

March 21, 2024

FAIR Health commercial claims data can inform Medicaid programs, as it is doing in New Hampshire. FAIR Health’s repository of over 46 billion private healthcare claim records can provide a useful backdrop for Medicaid officials in informing dispute resolution and fee schedule development and studying treatment protocols and utilization patterns.

Dispute Resolution
If a Medicaid claim is disputed, states can use FAIR Health medical and dental benchmarks to research the allowed amounts in the private insurance market. This can inform their decision-making process about the Medicaid claim. For example, the New Hampshire Department of Health and Human Services licenses FH® Allowed Benchmarks for internal purposes to inform its review of grievances under the Medicaid program.

Fee Schedules
FAIR Health’s medical and dental benchmarks can provide information to Medicaid program administrators in revising or updating fee schedules to encourage greater participation in provider networks. States can compare our commercial data with their Medicaid data to support development of fee schedules that may serve to attract more providers to participate.

Treatment Protocols
FAIR Health data can prove valuable in comparing treatment protocols in Medicaid programs to those in commercial populations. Such comparisons can reveal disparities in care (e.g., services rendered in connection with substance use disorders and mental health conditions) that might affect patient outcomes or the design of provider networks.

Utilization Patterns
Medicaid officials can use FAIR Health data to study utilization patterns. For example, by comparing follow-up visits in commercial versus Medicaid populations, they can see if patients adhere to follow-up regimens more in one than the other. Medicaid administrators can also learn about changes in the commercial system that might be relevant to their programs. Our data, for example, illuminate increased use of telehealth and retail clinics in recent years, and changes in specialties—notably, how nonphysicians are increasingly offering primary care and rendering mental health services.

In supporting Medicaid programs, FAIR Health is continuing our tradition of serving states in many capacities as a neutral provider of reliable data and services. Among other areas in which FAIR Health works with states are workers’ compensation programs, auto liability, surprise billing, state crime victims’ funds, women’s wellness and cancer screenings, and a medical indemnity fund for birth-related neurological injuries.

FAIR Health President Robin Gelburd stated: “We are delighted at how our rich repository of commercial claims data adds value to Medicaid programs in a variety of ways.”

For more information about the services and data products FAIR Health offers to state Medicaid programs, contact FAIR Health by email at info@fairhealth.org or call 855-301-FAIR (3247), Monday through Friday, 9 am to 6 pm ET.