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;
- 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 nonfacility fee schedules in a single format and fills in the gaps with FAIR Health data.
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. The insurer had previously outsourced processing for these services or reimbursed based on a percentage of Medicare. By licensing these additional facility modules, it was able to replace multiple workflows with a uniform, streamlined and cost-effective claims adjudication process.