How FAIR Health Can Support Medicaid Programs

FAIR Health has become increasingly useful to states seeking to analyze and reform their Medicaid programs. Among other uses, FAIR Health data have helped states achieve improved access for Medicaid enrollees and study the performance of providers rendering care under Medicaid. We also have helped Medicaid programs evaluate their encounter data and editing processes to bring greater efficiency and accuracy to the programs.

Varieties of Support

One way FAIR Health can support Medicaid programs is by assisting in the evaluation of provider reimbursement levels that may discourage provider participation and limit access to care. The Medicaid fees for services can be compared against providers’ billed charges and insurers’ imputed allowed amounts in the FAIR Health commercial claims dataset. Based on that evaluation process, states can consider appropriate enhancements and revisions to their fee schedules.

FAIR Health private claims data also are relevant as a point of comparison to Medicaid programs with respect to utilization, treatment protocols, clinical venues and outcomes. FAIR Health data can help Medicaid programs evaluate provider performance.

FAIR Health data can assist states in advancing reform efforts involving the transition from fee-for-service to value-based purchasing methodologies. In addition to providing value-based payment reports to state Medicaid programs, we can help state reform efforts succeed by supplying insightful analytic reports to managed care organizations within the state. Such reports help managed care organizations transition to new value-based reimbursement platforms by allowing them, among other things, to evaluate the performance of their networks and identify where there are concentrations of avoidable complications that could be addressed with additional training, quality measures and protocols.

Specified Medicaid Studies

FAIR Health studies have supported state Medicaid programs in their efforts to reduce errant denials and rejections within their Medicaid encounter data. Many different denials and rejections can occur between receipt of an encounter and payment for that encounter. FAIR Health has worked on several Medicaid data analyses to assess the appropriateness of such denials and rejections.

FAIR Health conducts “root cause” analyses of why data are denied or rejected and whether the bases for these determinations are sound. Sometimes “bugs” in the logic for a rule cause errant denials. Other times there can be nuanced changes to medical coding that may not be captured in a timely manner by the state. After conducting the analyses, FAIR Health makes concrete recommendations regarding the edits employed by the state program to reduce the number of invalid rejections.

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