FAIR Health is a national, independent nonprofit organization whose mission is to bring transparency to healthcare costs and health insurance information through comprehensive data products, consumer resources and the support of health services research.
FAIR Health uses its database of billions of billed medical and dental services to:
- Create data products, custom analytics and interactive data dashboards that FAIR Health licenses to health plans, insurers, third-party administrators, employers, unions, healthcare professionals, hospitals and health systems, government agencies, policy makers, researchers and others. With our professional staff of experts in healthcare, statistics, technology and consumer education, FAIR Health strives to offer information to all stakeholders in the healthcare sector.
- Power an award-winning, free website (fairhealthconsumer.org) that enables consumers to estimate and plan their medical and dental expenditures. FAIR Health Consumer also offers clear, unbiased educational articles and videos about the fundamentals of health insurance. Our cost lookup tools and educational material about healthcare costs and insurance are offered in Spanish at fairhealthconsumidor.org. Based on FAIR Health Consumer, FAIR Health can develop a private-label website or mobile app, customized to reflect an individual client’s branding.
- • Support research on all aspects of the healthcare delivery system. These studies include those developed by the FAIR Health team and those developed by external researchers for publication in journals and government reports.
FAIR Health was founded in 2009 after then-New York State Attorney General Andrew Cuomo conducted an investigation into perceived conflicts of interest involving the adjudication of claims. The Office of the Attorney General reached settlement agreements with health insurance companies that do business in New York State, and FAIR Health was established as part of this settlement. FAIR Health was formed as an independent organization to bring transparency, integrity, reliability and accessibility to healthcare costs and insurance information for all healthcare stakeholders. Our mandate was to provide an independent database of claims information contributed by payors nationwide, a free website to educate consumers about the cost of care in their geographic areas and insurance reimbursement, and data for research that could help to formulate or evaluate policy and support academic studies.
While the investigation took place in New York, the settlement had national implications. Since our inception, FAIR Health has established a national reputation for bringing cost transparency to the healthcare sector. FAIR Health maintains and makes available trusted claims data resources used to promote sound decision making by participants throughout the healthcare system nationwide. Although not a government agency, FAIR Health serves as the authoritative, official data source in numerous governmental programs.
FAIR Health’s purpose is to bring transparency to healthcare costs and health insurance information. It fulfills this purpose by leveraging the largest collection of private health insurance claims in the nation, along with separate data covering 100 percent of Parts A, B and D of the Medicare program, to create comprehensive data products, custom analytics, interactive data visualizations, consumer resources and health systems research support.
FAIR Health is unique because of its history; track record of independence; corporate structure as a nonprofit governed by a premier, conflict-free, uncompensated Board of Directors; data resources; accomplishments; and valued role in the healthcare sector. As an independent, unbiased source of healthcare cost information, FAIR Health is the trusted data provider to a wide range of clients, including payors, healthcare professionals, hospitals and health systems, government agencies, unions, consultants, pharmaceutical companies, employers, consumers and researchers.
FAIR Health serves a broad range of healthcare stakeholders in various industries, including but not limited to:
- Hospitals and healthcare facilities;
- Physicians and dentists;
- Property and casualty administrators;
- Technology innovators;
- Associations and medical societies;
- Legal entities; and
- Life science companies.
Stakeholders use FAIR Health data in a great variety of ways. Some examples include:
- Out-of-network (UCR) fee schedule development;
- Reference point for legislated consumer protections and state health programs;
- In-network fee schedule development;
- Workers’ compensation and auto liability program fee schedule development;
- Claims adjudication;
- Cost transparency tools;
- Public and private exchange plan selection and management;
- Facilitation of expansion decisions;
- Employee and member education;
- Reimbursement risk management;
- Network design and provider recruitment;
- Provider fee schedule evaluation;
- Benefit design;
- Healthcare cost projections and trending reports;
- Market research;
- Sales and inventory planning;
- Dispute resolution;
- Research and policy development;
- Population health analyses; and
- Patient outcome studies
To keep abreast of news about FAIR Health, you may subscribe to receive FAIR Health emails and choose the topics you are interested in, from general company news (including our newsletters FAIR Health Access® and FAIR Health Consumer Access®) to our line of products. You can also connect with us through social media on Facebook, LinkedIn, Twitter and YouTube.
FAIR Health obtains its data from more than 60 health plans, insurance carriers and third-party administrators who contribute claims data through the FAIR Health Data Contribution Program described below.
The FAIR Health National Private Insurance Claims (FH NPIC®) database is made up of de-identified data from billions of privately billed claims for medical and dental services submitted by healthcare professionals to health insurers across all 50 states; Washington, DC; Puerto Rico; and the US Virgin Islands. The database includes over 33 billion billed procedures, from 2002 to the present. The database grows continually as new data are received each month; we receive approximately two billion new claim records each year. The data are submitted to FAIR Health by healthcare payors and administrators who insure or process claims for private insurance plans covering more than 150 million individuals in the private (i.e., non-government-sponsored) healthcare system. Approximately 65 million covered lives annually in the dataset can be tracked longitudinally.
In addition, because FAIR Health is certified by CMS as a Qualified Entity (QE), FAIR Health receives all of Medicare Parts A, B and D claims data for use in nationwide transparency efforts. As a QE, FAIR Health holds data representing the experience of all individuals enrolled in traditional Medicare from 2013 to the present (as well as Medicare Advantage enrollees represented in our private claims data). FAIR Health can produce insightful analytic reports and data products based on combined Medicare and commercial claims data for government, providers, payors and other authorized users.
FAIR Health places the highest priority on patient privacy and the security of our contributors’ data. We apply rigorous protocols to de-identify all personally identifiable patient information, in accordance with the Health Insurance Portability and Accountability Act (HIPAA) and other requirements. We also exclude from our data products any information that could identify a patient, plan or contributor. Our security policies and procedures meet or exceed the industry’s most exacting standards, as demonstrated by our HITRUST, SOC 2 and CMS QE certifications. To learn more, visit Security.
FAIR Health owns and manages its database. FAIR Health has worked with advisors from the academic and research community to help shape the statistical methodologies and algorithms employed to develop and enhance the value of its data products.
FAIR Health applies rigorous quality assurance processes to validate data before they are accepted by the FAIR Health Data Contribution Program and added to the repository. Each data submission undergoes a series of thorough edit checks by in-house experts in statistics, mathematics and information technology to help prevent flawed data from being included. Part of this process involves testing the data with statistical algorithms to ensure that invalid entries are eliminated. For example, FAIR Health identifies and quarantines claims data with invalid dates of service and/or invalid zip codes. To learn more visit Validation.
FAIR Health collects most data fields reported on medical and dental claims, including diagnoses, procedures, dates and places of service, billed charges, allowed amounts reimbursed and other information. All types of services are captured in the repository, including lab services, surgeries, radiology, durable medical equipment, emergency services, behavioral health, ambulance services, specialty drugs, primary care and the like. The data also include place of service and provider specialty, as well as the age and gender of the patient.
The FAIR Health database includes claim records from all geographic areas in the United States and its territories, including all 50 states; Washington, DC; Puerto Rico; and the US Virgin Islands. FAIR Health’s repository does not include claim records from outside the United States. The geographic location in our data indicates where the service was rendered. FAIR Health data are organized into 493 geozips, which tend to track with the first three digits of a zip code. Click here to download a complete listing of geozips.
Yes. The FAIR Health private claims database holds more than 30 billion claim records from plans that cover an estimated 75 percent of the privately insured population in the United States. The private claims database has been determined to meet sufficiency thresholds and the requirements for research sample size and reliability with respect to the privately insured population in all 50 states and the District of Columbia by the federal Centers for Medicare & Medicaid Services.
FAIR Health Products and Solutions
FAIR Health makes its data available in a range of formats to a variety of stakeholder groups. These include benchmark data products, custom analytics and consumer engagement tools. FAIR Health also offers a separate website for consumers at fairhealthconsumer.org (fairhealthconsumidor.org in Spanish), with mobile versions available through the App Store and Google Play. You can learn more by visiting the Solutions section.
FAIR Health offers FH® Benchmarks, a suite of modules that aggregate claim records from the FAIR Health database by official healthcare code and geozip, and array benchmarks for each procedure code/geozip combination into percentiles. FH Benchmarks include the following modules:
- FH® Charge Benchmarks: Medical, Dental, Anesthesia, HCPCS, Category III, Urgent Care, Inpatient Facility DRG, Inpatient Facility ICD Proc/Rev,
Outpatient Facility, ASC Facility and Facility HCPCS (coming in April).
- FH Charge Benchmarks are based on providers’ nondiscounted, billed charges.
- FH® Allowed Benchmarks: Medical, Dental, Anesthesia, HCPCS and Outpatient Facility.
- FH Allowed Benchmarks approximate the fees that may be negotiated between insurers and providers for a particular service or procedure in a geographic area when performed in network.
- FH® Medicare GapFill PLUS: To support fee schedule development, this product consolidates all nonfacility CMS fee schedules and fills in the gaps (i.e., the services CMS does not value) with values developed by applying to FAIR Health data the scale used by CMS for Medicare fees.
FAIR Health benchmark modules are refreshed twice yearly to reflect more recent data collected and included in the FAIR Health claims database. Product modules include 12 recent months of data that are updated for each release.
FAIR Health offers benchmarks for three codes for COVID-19 testing that have been newly created by CMS and the American Medical Association’s CPT® Editorial Panel:
- CPT 87635—Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique;
- HCPCS U0001—Centers for Disease Control and Prevention (CDC) 2019 Novel Coronavirus Real Time RT-PCR Diagnostic Test Panel; and
- HCPCS U0002—2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC.
FAIR Health, together with its statistical experts, has developed and employs an extreme outlier methodology to detect and remove data entries that may represent invalid charge data from its benchmark products.
To address small cells (i.e., procedures performed at a very low frequency in a particular geographic area), FAIR Health employs a derived or relative value methodology. To learn more, visit the Methodologies section.
No. FAIR Health offers benchmark data to assist multiple stakeholders for many purposes, including to assist insurers in establishing their own usual and customary rates (UCR) for out-of-network reimbursement decisions. FAIR Health does not set UCR rates or out-of-network reimbursement amounts; those determinations are made by insurers themselves. FAIR Health data are intended to inform those decisions.
FAIR Health staff work with our clients to create custom data analyses and aggregated datasets to meet their specific needs. We also create interactive data dashboards and visualizations that illuminate findings. Examples of customized analyses include:
- • Geographic variations in treatment protocols and costs;
- • Clinical incidence;
- • Analysis of service utilization patterns;
- • Patient migratory patterns;
- • Patient outcomes and complications;and
- • Social determinants of health;
The claims data that FAIR Health receives are contributed by payors voluntarily through the FAIR Health Data Contribution Program. In consideration of their contributions, contributors receive credits against their license fees for FAIR Health data products, as well as other incentives, such as complimentary data auditing and validation dashboards, complimentary data reports and eligibility to license nonpublic reports combining both Medicare QE and commercial data. In addition, by contributing their data, these organizations ensure that their claims experience is represented in the aggregated data that support a growing list of statutes, regulations and official memoranda incorporating FAIR Health data as a governing benchmark. Moreover, a large data pool makes FAIR Health data products truly representative of the private insurance market and enables FAIR Health to develop new data products and custom analytics to serve the healthcare industry and its many stakeholders.
Health plans, insurance carriers and third-party administrators may contribute claims data to FAIR Health. FAIR Health regrets that it cannot accept claims submissions from healthcare practitioners, due to the high probability that provider claims will result in the duplication of data already within the database. However, FAIR Health can take in and separately house distinct claims data from providers, government agencies and other entities for specific projects, such as custom analytics.
FAIR Health is able to accept data in a variety of formats and file types. We do not require any special standardization or configuration on the part of the contributor. The FAIR Health data team works closely with new contributors to establish and securely transfer the test file in order to get your organization’s data contribution up and running quickly and easily according to contribution guidelines. We standardize and map the contributed data on our end in order to assure that all of the data fields from contributors are comparing “like to like” elements. We also will monitor your contribution feeds and provide guidance as needed.
Participants in the data contribution program earn discounts of up to 50 percent off licensing fees for FAIR Health data products.
In addition, on a submission-by-submission basis, data contributors will have access to interactive data auditing and validation dashboards that can help with quality assurance for their data submissions and that offer additional analyses. On an annual basis, data contributors will have access to data comparison reports—i.e., in-depth analytics that compare their claims data with our broader, aggregated repository. The reports offer valuable market insights.
Yes, FAIR Health provides all contributors with telephone- and web-based training for the initial setup and ongoing data submission process.
FAIR Health Support
FAIR Health is committed to serving clients with support tailored to their needs. FAIR Health offers various levels of assistance to clients, including answers to questions about its data and methodologies, training sessions and webinars via conference call, and specialized support that includes on-site training and hands-on assistance with a variety of service, product and client education topics. To learn more, visit the Support section.