Reliable, Robust Claims Data Support Key Payor Functions

Health insurers, third-party administrators (TPAs), collectively bargained plans, self-insured employers and other payors and claims processors seek robust, market-based data upon which to base their reimbursement decisions and fee schedules—data that are a reliable reflection of what healthcare services cost in today’s marketplace. FAIR Health’s FH^® Benchmarks and FH Custom Analytics meet those needs. Payors nationwide license our data and solutions for a broad range of functions, including:

• Auto-adjudicating out-of-network claims by licensing our FH Charge Benchmarks and loading them into the payor’s own claims processing system or a vendor-provided solution;
• Using our FH Charge Benchmarks to develop usual, customary and reasonable (UCR) reimbursement fee schedules for out-of-network claims;
• Using our FH Allowed Benchmarks for network management, negotiating with providers and creating in-network fee schedules;
• Comparing benchmarks to charges of high-value providers and/or centers of excellence when negotiating network participation;
• Learning how their fee schedules—both for in-network and out-of-network services—compare to local markets and, by extension, their competitors;
• Analyzing utilization data to understand geographic and clinical trends to inform benefits design and pricing;
• Engaging FAIR Health to analyze their claims data through our FH Episodes of Care Analytics engine to help prepare for value-based reimbursement, identify best practices and manage networks;
• For organizations that don’t have complete claims data, licensing FH Episodes of Care Benchmarks to evaluate their experience in comparison to local market areas;
• Licensing a private-label version of our consumer website to provide transparency and help educate members about their insurance coverage—or licensing our data for use inside a member portal to contrast in-network and out-of-network costs; and
• For payors who reimburse based on Medicare fees, licensing our FH Medicare GapFill PLUS, a product that seamlessly provides Medicare non-facility fee schedules in a single format and fills in the gaps with FAIR Health data

Market Cost and Utilization Trends Shape Business Strategy

Patients today have unprecedented choice in where to receive care. Of course, the quality of care is most important, but once the standard of quality is assured, patients often base their decisions on cost, convenience, location and the terms of their benefit plans. To help ensure a steady stream of patients, many hospitals, other facilities and physician practices are forming integrated healthcare systems that offer one-stop shopping for a variety of types of care. Effective strategic decisions about consolidation, expansion, network building and competitive pricing models for these systems must be based upon reliable information about market-level costs and geographically specific trends in service utilization and in venues of care.

Healthcare systems, individual hospitals, ambulatory surgery centers (ASCs), urgent care centers, retail clinics and other types of facilities rely on FH^® Inpatient Facility, FH Outpatient Facility and FH ASC Facility benchmarks to evaluate facility billing and our professional service benchmarks to gauge staffing costs, as well as FH Custom Analytics tailored to their needs, to perform a wide range of functions, including:

Market Charge Data to Support Key Business Decisions

Easy access to market-level billed charges by locality informs the critical business decisions that keep practices running smoothly and profitably—enabling practitioners to focus on patient care. Dentists, physicians, practice managers and other healthcare professionals use our convenient and affordable FH Fee Estimator^®, an interactive website tool to access charge benchmarks for their clinical specialties and practice locations. They can search and download information for a variety of functions, among them:

Claims Data to Predict Product Use and Revenue

FAIR Health offers the developers, manufacturers and marketers of clinical and life science solutions the rare opportunity to view in a single dataset trends in market-level data including utilization, cost and the demographics and geographic location of the patients who use or might need the services or devices they offer. Our unique, actionable analytics and record-level data offer insights into clinical practice patterns, help assess the commercial market for products related to medical services or diagnoses and support research into life sciences solutions—and thereby provide a reliable basis for revenue projection, inventory management and return on investment.

R&D analysts, product managers, commercial and clinical researchers, pharmaceutical and durable medical equipment (DME) manufacturers and distributors—and their research funders, investors and advisors—can turn to FAIR Health’s record-level claims data, aggregated benchmark data and custom analytics for many functions, among them:

Independent, Credible Data to Power Tomorrow’s Technology Solutions

In today’s changing healthcare environment, innovative technology solutions require data that can enlighten the market and, at the same time, satisfy stakeholders’ standards for credibility. To help ensure that cutting-edge applications and systems are reliable, competitive and of maximum utility to users, technology innovators need data that represent a comprehensive, up-to-date record of services being utilized and their market-level costs—from an independent, conflict-free source.

A trusted resource maintaining the private claims data that businesses, policy makers, state governments, researchers and consumers alike depend upon, FAIR Health offers allowed amount and billed charge benchmark data for a wide range of service types, as well as custom analyses and de-identified, record-level claims data that can shed light on health conditions, public health issues and utilization. Available in an array of formats easily incorporated into most systems and configurations, our FH^® Benchmarks and FH NPIC^® (National Private Insurance Claims) data can be used to feed technology applications, build alternative reimbursement models, power healthcare applications and much more.

Examples of the many ways FAIR Health data can be a key ingredient in technology solutions include:

• FAIR Health data can fuel cost calculators;
• Claims solution vendors can load our FH Benchmarks into their claims processing platforms;
• Technology consultants can use our data to help clients effectively manage their reimbursement cycle; and
• Business consultants can use our FH Episodes of Care Benchmarks to help clients project expected costs and build value-based reimbursement models.

A Neutral, Recognized Foundation for Public Programs and Policies

FAIR Health statistical data and custom analytics are relied on by government policy makers nationwide. Numerous government agencies use our independent, conflict-free healthcare cost and utilization data as a reference point when setting new healthcare cost policies and regulations, evaluating existing standards, processing claims for government-sponsored health programs, supporting benefits administration for government employees and much more.

Our FH® Benchmarks provide an array of current, objective data points reflecting providers’ charges and allowed amounts used by insurers when paying claims for services in geographically specific areas. FAIR Health can create FH Custom Analytics of the underlying data to meet particular needs. The many uses of our data by government entities include:

• Establishing benchmarks for medical fees for balance-billing legislation;
• Measuring the impact of statutes, regulations or public health initiatives by comparing before-and-after snapshots, using the FH NPIC® (National Private Insurance Claims) longitudinal line-level data;
• Developing or updating workers’ compensation fee schedules;
• Setting reimbursement standards for personal injury protection (PIP), i.e., auto liability insurance;
• Evaluating Medicaid fee schedules for cost and access issues;
• Assessing Medicaid network adequacy in terms of practitioner specialty and geographic coverage;
• Adjudicating claims for government employee medical and dental plans;
• Referencing our benchmarks to assist with dispute resolution proceedings;
• Valuing indemnity funds;
• Framing public health education campaigns and interventions;
• Setting legislative priorities; and
• Identifying emerging clinical trends.

Line-Level Claims Data, Trackable over Time

Academics, policy makers, clinical researchers, commercial R&D analysts, think tank members and others are advancing their research with FAIR Health data. Offering the nation’s most complete picture of the costs and utilization of privately billed medical and dental procedures—including more than 25 billion claim records dating back to 2002—the information in our FH NPIC^® (National Private Insurance Claims) database provides insights into a wide range of topics, among them trends in practice patterns, clinical issues, diagnoses and geographic variations in healthcare prices and payor mix.

Based on researchers’ specifications, FAIR Health can extract custom datasets presenting line-level data, including de-identified member ID trackable over time, patient age and gender, ICD-9 and ICD-10 procedure codes, geographic specificity, specialist type and more. Our data can inform a broad spectrum of studies, such as:

• Identifying trends in utilization and cost across places of service/venues of care;
• Using de-identified member data to track a patient’s beginning-to-end treatment path;
• Tracking trends in diagnoses over time;
• Illustrating a hypothesis with the support of real-world data;
• Conducting population health analyses;
• Studying current issues affecting the national healthcare system, such as the impact of the opioid epidemic on healthcare costs; and
• Assessing the influence of regulations, such as the utilization of naloxone before and after the enactment of laws that promote or limit its use to prevent overdose deaths.

Wide Range of Research Topics Permitted

FAIR Health makes data available to researchers regardless of the proposed research topic, and we require no Institutional Review Board (IRB) approval before licensing those data. And, our licensing fees are compatible with most research budgets.

Actionable Claims Data Meet Organization Members’ Needs

Many national and state-based associations, medical and dental societies and other organizations are seeking a resource to help their membership understand fees in their local areas. FAIR Health’s FH^® Benchmarks for billed charges and allowed amounts, available in multiple formats, can provide association members access to the claims-related information they need, at an affordable cost. Associations and other membership-based groups turn to FAIR Health for flexible ways to access data that can meet their business needs, including:

• National and state medical and dental societies can make FH Fee Estimator^® available to their practitioner membership by clinical specialty and geographic area as a special benefit, at discounted rates;
• For associations with broad membership not limited by specialty or geography, FH Online can provide users with a wider range of geographical areas, code ranges and claim types; and
• Association leadership finds our FH Benchmarks valuable for use in formulating proposals to advocate for their members and to help evaluate the impacts of policies and legislative proposals on their membership.

FAIR Health works with associations in many ways to help members gain access to our data products and tools. We can make discounts available to association members who license FAIR Health products and provide reduced license fees to associations wishing to use data on behalf of their members.

Transparent, Reliable Claims Data—Actionable Results for Clients

Healthcare consultants thrive by consistently delivering insightful solutions on which their clients can count. That’s why consultants turn to data that are broadly accepted for their transparency, completeness, accuracy and currency. We at FAIR Health work closely with our consultant clients to help them craft custom solutions that will provide strategic and operational advantages to their customers. Examples of solutions using FAIR Health products and custom analytics include:

Consultants Serving Employers, Payors and Benefits Managers

• Our FH^® Charge Benchmarks and FH Allowed Benchmarks combine to offer a comprehensive view of current market experience, including benefits utilization and costs. Consultants can evaluate their clients’ claims experience by market area through a targeted comparison to our FH Benchmarks.
• Our service-specific FH Benchmarks identify a wide range of cost and utilization trends. For example, our FH Outpatient Facility and FH ASC Facility for ambulatory surgery center costs provide information about emerging venues of care that can inform benefits design and budget forecasting.
• Consultants can use our FH Episodes of Care Benchmarks to demonstrate the implications of moving to value-based reimbursement systems; FH Episodes of Care Analytics can be used to evaluate the client’s own claims data through a bundled-service lens, enabling them to evaluate costs, provider best practices and a number of dimensions that can influence outcomes.
• Consultants can help clients improve member and employee health insurance literacy and access to cost information through private-label versions of our FH Consumer website and English/Spanish mobile application, FH Cost Lookup/FH CC Salud. Claims adjustors and customer service staff assisting consumers with questions regarding the cost of services can also use our tools.
• Consultants working with payor clients that reimburse based on Medicare fees can benefit from the completeness and convenience of our single-source FH Medicare GapFill PLUS product.
• FAIR Health’s FH NPIC^® (National Private Insurance Claims) data and FH Custom Analytics can be used to understand the venues of care where services take place, charge differentials by specialist type and prevalence of diagnoses by demographics and geography—all of which can inform benefit design, pricing models and network negotiations.
• Our FH NPIC longitudinal data can provide insights into comorbidities and treatment patterns that help structure wellness and disease management programs and provide a deeper understanding of utilization.

Consultants Serving Providers, Healthcare Systems and Others.

• Consultants request FH Custom Analytics created to their specifications in performing due diligence for clients pursuing mergers and acquisitions in the healthcare sphere. FAIR Health data support informed decisions by uncovering risk, projecting revenue growth and identifying potential economies and cost reduction.
• Consultants can develop longitudinal studies based on our de-identified patient data to help clients to track patient-specific treatment patterns, clinician types and associated costs.
• FH Episodes of Care Benchmarks can help hospitals to identify patient “leakage” outside of their system and to develop strategies to optimize the care of a patient across affiliated facilities and practices.
• Our FH Benchmarks reveal the economic factors required to inform decisions to expand into new markets.
• FH Fee Estimator^® enables consultants working with medical practices to assist their clients by creating and maintaining fee schedules appropriate for their local market.

Shedding Light on Auto Liability Claims and Workers’ Compensation Bills

Property and casualty (P&C) insurers, third-party administrators (TPAs), bill review companies and other organizations involved in determining costs associated with auto accidents and workers’ compensation cases seek a trusted, defensible source of cost information upon which all parties can agree. These businesses license FAIR Health’s FH^® Benchmarks and FH Custom Analytics as a reference point for a broad array of functions, including:

• Processing workers’ compensation bills;
• Finding values for codes not included in Medicare-based workers’ compensation fee schedules, using our FH Medicare GapFill PLUS product;
• Helping to resolve disputes and determine costs associated with injuries and illnesses for auto liability claims. Our reliable, trusted data can be used to value a settlement that helps avoid costly litigation;
• Calculating the “value of paid bills” using our FH Allowed Benchmarks. This is often an important component of a settlement, used either for real expenses or as part of the calculation of pain and suffering damages (which also could be based on a multiple of FAIR Health’s medical cost benchmarks); and
• Licensing FH Custom Analytics that show trends by procedure type.

Benchmark information is available in multiple formats, including through FH^® Online, spreadsheets or data tables that can be loaded to internal systems.

An Independent Data Source for Payment Disputes and Settlements

When parties disagree over appropriate payment for a healthcare procedure or service, a critical step to reaching a resolution is agreeing to a neutral, unbiased and statistically reliable reference point against which to compare the disputed amount. Law firms, consultants, arbitrators and others recognize FAIR Health as their trusted, independent source for defensible, robust, up-to-date and geographically specific claims data. Uses of FH^® Benchmarks and FH Custom Analytics in disputes and settlements include:

• Utilizing claims data—including FH Charge Benchmarks and FH Allowed Benchmarks—to support a position in a dispute over fees for auto liability, workers’ compensation or group healthcare out-of-network claims;
• Valuing a settlement that includes cost projections for medical care for a specific injury or condition that may last years or a lifetime. For disputes regarding complex injuries or conditions, FH Episodes of Care Benchmarks can be used to determine costs for all related procedures, adjusted for risk profiles and comorbidities;
• Challenging data provided by an opposing party in a legal dispute. The underlying objectivity and reliability of FAIR Health data can be a deciding factor if the other party’s source is less reputable or robust;
• Using our FH Medicare GapFill PLUS product to identify values for codes not included in the standard Medicare fee schedule in disputes where reimbursement is based on a percentage of Medicare fees;
• Employing case-specific statistical information and histogram visualizations as evidentiary support to determine if a provider’s charge is reasonable;
• Evaluating potential outcomes in advance of pursuing an appeal or other legal challenge; and
• Fostering mutual agreement by opposing parties to use a particular FAIR Health benchmark to determine costs as part of a settlement.