Several states have enacted laws to protect consumers from “surprise billing” and the federal No Surprises Act (NSA) takes effect on January 1, 2022. FAIR Health currently offers solutions for a number of individual states’ surprise billing laws and has developed an offering to support the “Qualified Payment Amount (QPA)” provisions of the NSA. This FAIR Health suite of products is a valuable resource to assist health plans, providers and arbitrators in determining reimbursement amounts under these laws.

State Solutions

Many states have laws that protect patients from balance billing, and the scope of these protections varies. FAIR Health data serve as the independent, official data source for surprise billing laws in the following states:

• Connecticut
• Georgia
• New Mexico
• New York
• Texas

Many organizations rely on FAIR Health benchmarks, including in states that do not specifically refer to FAIR Health in their statutes or regulations.

Support for the Federal No Surprises Act (NSA)

The federal NSA applies to health plans in states that do not have a specific state law concerning surprise bills, and to self-insured health plans that are not covered by such state laws. The NSA requires plans to calculate patients’ cost-sharing responsibilities for certain surprise medical bills using the plan’s Qualifying Payment Amount (QPA). The QPA is the payor’s historic median contracted amount for each procedure code in each market and geographic area it covers. When payors have insufficient provider contracts to calculate the applicable median contract amount for a specific service, they must use an independent third-party database to calculate the QPA and determine the patient’s cost-sharing obligations.

Plans can use FAIR Health data in the FH® NSA Reference File to help calculate the QPA in these situations. In addition, the data may inform the plan’s selection of an initial payment amount to out-of-network providers, potentially reducing disputes and the need for arbitration. The data may also prove useful for all stakeholders in preparation for arbitration and dispute resolution.

Data available in the FH NSA Reference File include medical, HCPCS, anesthesia, outpatient facility, inpatient facility ICD procedure code/revenue code and inpatient facility DRG. For all these types of services, the FH NSA Reference File provides median allowed amount benchmark values at various levels of geographic aggregation (e.g., Metropolitan Statistical Area, among others) to support organizations affected by the NSA.

For more information, contact us by email at info@fairhealth.org or call us at 855-301-FAIR (3247), Monday through Friday, 9 am to 6 pm ET.

The FH NPIC (National Private Insurance Claims) database—our industry-leading collection of privately billed medical and dental procedures—is based on data contributions from payors nationwide. FAIR Health collects all data fields reported on medical and dental claims, including diagnoses, procedures, dates and places of service. FAIR Health licenses de-identified, aggregated datasets where appropriate for academic, policy and commercial research.