National Benchmark Pricing for Episodes of Care

April 01, 2017

Allowed and charge amounts adjusted for comorbidities and risk factors

Based on market-level claims data for the full range of procedures involved in the treatment of common conditions—and enabling the adjustment of estimates to address common comorbidities and risk factors—FH® Episodes of Care Benchmarks provides the unique view of per-episode healthcare costs for which payors, researchers, policy makers and businesses have been waiting.

Until now, the healthcare sector’s move toward value-based reimbursement has been complicated by the lack of an information source that can provide geographically specific, real-world cost data for all procedures associated with common conditions—and demonstrate how those costs change based on the patient’s risk profile and the presence of common comorbidities.

Using the PROMETHEUS Payment® model of the Health Care Incentives Improvement Institute (HCI3), FH Episodes of Care Benchmarks provides essential insights into value-based reimbursement and related pricing studies. FAIR Health’s episodes benchmarks enable users to project costs based on patients’ conditions, risk profile, and likely duration of care; negotiate with providers to build and maintain networks; negotiate with payors and healthcare systems for network participation; evaluate business acquisition, expansion and contraction; and more. FH Episodes of Care Benchmarks includes: • Information on the patient’s beginning-to-end treatment path; • More than 40 defined episodes, from diabetes care to knee replacement; • Aggregated allowed amounts and billed charges; • Ability to choose both the episode and the “trigger code” for the service (e.g., identified by CPT code) that initiated the episode; • Application of up to five common comorbidities and five risk factors; • Benchmark pricing based on claims aggregated at the 50th and 80th percentiles for each of 493 geozips; • Ability to customize each episode based on business needs, treatment protocols and/or plan design; • HCPCS, Medical/Surgical, Anesthesia and Outpatient Facility values, plus average hospital room and board rates based on the calculated length of stay; and • Pricing for the overall episode plus line items showing costs and quantities of the individual procedures that compose the episode. For information about how FH Episodes of Care Benchmarks can inform your organization’s strategic decisions and analyses, contact us by e-mail at service@fairhealth.org or call us at 855-301-3247, Monday through Friday, 9 am to 6 pm ET.

Also of Interest

Click here to learn about FH Episodes of Care Analytics. With this supplemental offering, FAIR Health will process three years of your organization’s medical claims, identify your group’s episodes of care and drill down to the procedures, frequencies and associated costs to inform strategies for improved quality and/or cost savings.

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