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.
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.