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:
Adding FAIR Health Modules Enables Streamlined In-House Processing
A major insurer that has long used FH Medical benchmarks for adjudicating out-of-network claims for medical services added other FAIR Health benchmark modules, FH Inpatient Facility, FH Outpatient Facility and FH ASC Facility. They had previously outsourced processing for these services or reimbursed based on a percentage of Medicare. By licensing these additional facility modules, they were able to replace multiple workflows with a uniform, streamlined and cost-effective claims adjudication process.
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:
Fee schedule creation
With FAIR Health cost information available by facility type, procedure code and geographic area, healthcare systems can determine where their fees stand relative to the market area, and establish a pricing model that fits their objectives.
Expansion and network building
Our data support decisions on where to locate offices, which types of specialists those offices might need (based on which diagnoses are commonly seen in the area) and strategies for negotiating with those specialists (using our professional fee modules).
Interpreting Trends in Venues of Service
FAIR Health data can identify shifts in where services are delivered—indicating, for example, that in a given area, hospitals may be losing market share to ASCs, urgent care centers and retail clinics and might want to consider affiliating with or buying such facilities.
Our line-level FH NPIC® (National Private Insurance Claims) data can support research conducted by affiliated physicians with de-identified member IDs—such as longitudinal studies of a patient’s treatment path—and yield information on diagnoses, venues of service and more.
Hospitals and healthcare systems can strengthen relationships with patients by helping them understand the cost of healthcare and how insurance works. Facilities can license a private-label version of FH Consumer, FAIR Health’s consumer site, or provide a link from the hospital’s website to our consumer site, to help patients understand the potential costs of care and encourage them to check their coverage with their insurer in advance of treatment. Making consumer tools available to patients in admitting offices when they are completing pre-admission paperwork or in billing offices post-service also can help patients understand their coverage and reduce the burdens for customer service staff.
Location, Location, Location
An ASC company interested in opening facilities in other regions could analyze claims data available through FAIR Health’s FH ASC Facility benchmarks. By evaluating recent trends in place of service and price, they could project revenue in neighboring states and create an expansion strategy offering the best potential for success.
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:
Fee schedule creation
When developing fee schedules, practitioners can rely on an independent resource that offers market-level charge benchmarks by procedure code to help establish and update fee schedules, which can be easily uploaded to a practice management system. A handy workbook feature enables practitioners to model fee schedules based on how often they perform individual procedures.
Our FH® Benchmarks provide credible information that can help practitioners decide whether to participate in a network.
Our region-specific charge benchmarks paint a clear picture of market fees that can facilitate decisions about the economic feasibility of adding new specialties to a practice or expanding that practice to new locations.
An FH Fee Estimator license includes the ability to co-brand FAIR Health’s original articles explaining insurance and reimbursement—perfect for waiting room reading material. Practitioners also can add a link to FAIR Health’s award-winning FH Consumer website to the practice’s website.
Researching Equipment Lease to Benefit Practice and Patients
A physician considering the cost and potential benefit of leasing a CT scanner for her office could use FH Fee Estimator to look up the relevant codes to estimate the revenue that could be generated by performing CT scans in the office. If the return on investment for the equipment is positive, her decision could produce the dual benefits of providing convenient care for her patients while contributing to the practice’s bottom line.
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:
Findings based on our vast repository of privately billed claims data can supplement or validate research. Our de-identified member data allow longitudinal studies that include population health analyses and the assessment of the patient’s beginning-to-end treatment path;
An analysis of privately billed charges and allowed amounts benchmarks for specific procedures and services can help size the market and point out underserved geographic regions that might be suitable for expansion;
Manufacturers of medical equipment and devices can use our data to provide healthcare systems with insights about equipment utilization or to negotiate with carriers for reimbursement for a new device or drug treatment based on the value it brings;
Customer demographic analysis
Our data allow the creation of prospective customer marketing profiles, including procedure and location, diagnoses and comorbidities, de-identified member data and demographic information, such as age and gender; and
Product efficacy tracking
Our de-identified member data can track the patient’s care and provide insight into product efficacy. For example, data about de-identified patients who use a new opioid treatment might show subsequent trends in the incidence of overdoses.
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:
A Flexible Solution for Vendor and Clients
A technology solutions vendor uses its proprietary software platform to support claims adjudication for clients that license FAIR Health’s FH Benchmarks for claims processing. FAIR Health engaged directly with that vendor to review the formats that work best and to provide optimal support and service to the many clients we have in common.
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:
Estimating the Cost of Beneficiaries’ Long-Term Medical Care
Government agencies that oversee care for individuals with disabilities or special needs require data to support projections of the cost of care over the long term. Using FAIR Health’s data, a government agency can estimate long-term and even lifetime treatment costs so that appropriate funds are reserved. And, by using our FH Episodes of Care Benchmarks, analysts can look at costs for the full range of services related to many types of injuries and conditions—adjusted by common patient risk profiles and comorbidities—providing a more complete view of potential treatment costs.
As an independent, tax-exempt organization that qualifies as a public charity under section 501(c)(3) of the Internal Revenue Code, FAIR Health does not lobby or take a position on legislative or regulatory proposals.
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:
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.
Evaluating Care Quality in Relation to Price
Researchers from a leading academic institution used an FH NPIC dataset for their study of the correlation between the quality and efficiency of care delivered by physician practices and the prices charged to consumers for that care.
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:
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.
Bringing Healthcare Cost Data to Life Care Planners’ Fingertips
FAIR Health works with a national association of life care planners whose members use FH Online to access FH Benchmarks to estimate the cost of long-term care for major injuries and illnesses. Life care planners find it easy to use FH Online to research the cost of care by procedure and geographic area. Where previously planners were calling the many specialists in different geographic areas to estimate costs involved in a clients’ care over the course of many years, or even a lifetime, FAIR Health products streamline the research required to create life care plans. The association offers the FAIR Health solution as a key benefit to its members, who can license FH Online for a pre-arranged number of procedure code/geozip lookups, at a reduced rate.
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
Consultants Serving Providers, Healthcare Systems and Others.
Finding the Right Business Partner
An international consulting leader sought information on growth areas for mergers and acquisitions within the healthcare sector. It crafted an effective strategy by using FH Medical benchmarks to identify trends and combined those findings with FH Allowed Medical benchmarks to evaluate revenue growth potential.
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:
Benchmark information is available in multiple formats, including through FH® Online, spreadsheets or data tables that can be loaded to internal systems.
Informing the Decision to Litigate or Settle
In a challenge to the proposed reimbursement for treatment of an auto injury, a bill review company uses FAIR Health’s data to determine if the billed amount was in line with other charges or allowed amounts in the same specific geographic area for similar services. Using our data as a standard helps companies determine which challenges are worth the time and money to pursue through arbitration or litigation.
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:
Investigating Proper Payment for Injury Care
A multidisciplinary law firm needed to evaluate personal injury protection (PIP) claims against market costs for the reported healthcare procedures. By licensing FH Online to access FH Outpatient Facility benchmarks and FH Medical benchmarks, the firm quickly acquired the necessary information for conducting cost studies and effectively advising its clients on expense recovery.