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Payors

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

User Story

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.