Surprise Billing Solutions from FAIR Health

FAIR Health’s reliable and up-to-date data serve as an objective window into healthcare costs, and a valuable resource to assist health plans, providers and arbitrators in determining reimbursement amounts under surprise billing laws. FAIR Health serves as the official data source for several state surprise billing laws, and FAIR Health’s FH® NSA Reference File was specifically created to support compliance with the federal No Surprises Act.

Federal No Surprises Act

FH NSA Reference File supports plans, providers and IDR entities in complying with the qualifying payment amount (QPA) requirements federal surprise billing law. It presents median in-network allowed amounts, developed from FAIR Health's commercial claims database, for medical, HCPCS, anesthesia, outpatient facility and inpatient facility services. Values are provided by procedure code at geographic levels corresponding with the NSA regulations: individual Metropolitan Statistical Areas (MSAs), all MSAs in each state, all non-MSA areas in each state, all MSAs in each Census Division and all non-MSA areas in each Census Division. FH Allowed Benchmarks include a range of commercial, in-network allowed amounts from the 50th to the 90th percentile, organized by geozip (typically aligns with the first three digits of the servicing zip code). Both FH NSA Reference File and FH Allowed Benchmarks reflect commercial allowed amounts—and not NSA prohibited factors such as provider-billed charges, UCR or public payer rates (such as Medicare and Medicaid).

Payers and providers use the FH NSA Reference File and FH Allowed Benchmarks in numerous ways, including:

• Informing the plan’s selection of an initial payment to an out-of-network provider, helping to avoid disputes and reduce the need for arbitrations;
• Using the FH NSA Reference File to determine the QPA for services when the plan does not have sufficient information based on its own contracts; and
• Putting disputes in context with an understanding of typical in-network amounts for the service in a geographic area. If arbitration becomes necessary, plans and/or providers may submit data from these products for use in the NSA IDR process. The data can also be used by IDR entities to validate such submissions.

State Solutions

Many states have enacted surprise billing laws; the scope of these protections varies. FAIR Health data serve as an independent, official data source in the following states:

• Connecticut;
• Georgia;
• New Mexico;
• New York; and
• Texas.

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

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

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