Georgia Selects FAIR Health Data to Address Surprise Billing

Georgia has joined the growing list of states using FAIR Health benchmark data to address surprise billing. Georgia enacted a surprise bill law referencing “verifiable data,” and the data source selected was FAIR Health.

Surprise bills are those that are sent to consumers from out-of-network providers for emergency services or for nonemergency services unexpectedly rendered by an out-of-network provider at an in-network facility. Under Georgia’s Surprise Billing Consumer Protection Act, enacted in 2020 and effective in 2021, consumers are protected from paying more for a surprise bill than they would for an in-network bill. The law mandates that insurers must pay out-of-network providers either what the law calls the “verifiable contracted amount” or, if the provider was formerly in the insurer’s network, the most recent contract rate between the provider and insurer, whichever is greater.

As determined by Georgia’s Office of Commissioner of Insurance and Safety Fire, the “verifiable contracted amount” is defined by a custom benchmark provided by FAIR Health. The benchmark is based on the 50th percentile imputed allowed amounts in the August 2018 releases of FH® Allowed Medical and FH® Allowed Anesthesia, in 16 geographic areas in Georgia and statewide; the amounts are Consumer Price Index-adjusted annually.

If providers do not agree the mandated payment is reasonable based on the complexity and circumstances of the services, they may seek arbitration from a state-approved arbitrator. This will be “baseball arbitration,” meaning that the arbitrator must select one of the parties’ offered amounts, without modification. The information to be consulted by the arbitrator, including any FAIR Health benchmarks (if considered), are used only to assist the arbitrator in selecting the more reasonable offer.

State insurance laws generally cannot impose requirements on self-insured employer-sponsored plans, governed by the federal ERISA law. Georgia’s law, however, allows self-funded plans to elect to participate in and be bound by the state’s surprise billing law.

Other States
FH® Benchmarks already serve as official reference points for surprise billing laws in Connecticut, New Mexico, New York and Texas. In addition, many states rely on FAIR Health data as the designated source of cost information for a variety of state health-related programs, including workers’ compensation. FAIR Health provides a broad range of data and assistance to states, from supplying benchmarks that serve as standards for payment under various laws and regulations to helping evaluate economic and clinical trends and to supporting research with data and analytics.

FAIR Health President Robin Gelburd commented: “We are pleased to have been chosen by Georgia as an independent source of reliable, objective data with which to address surprise billing. FAIR Health has come to serve as a trusted nationwide resource for many state health-related programs.”

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