FAQ
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Background
- Who is FAIR Health?
FAIR Healthis a national, independent, not-for-profit corporation whose mission is to bring transparency to healthcare costs and health insurance information through comprehensive data products and consumer resources. FAIR Health uses its national database of billions of billed medical and dental services to power a free website that enables consumers to estimate and plan their medical and dental expenditures. The website also offers clear, unbiased educational articles and videos about the healthcare insurance reimbursement system. In addition to its consumer offerings, FAIR Health licenses data products to businesses, governmental agencies, healthcare providers and researchers. With its professional staff of experts in healthcare, statistics, technology and communications, FAIR Health strives to offer accurate, consistent and timely information to all stakeholders in the healthcare system.
- How did FAIR Health form?
FAIR Health was founded in 2009 after then-New York State Attorney General Andrew Cuomo uncovered potential conflicts of interest in the methods that health insurers were using to determine reimbursements to patients who received care from providers outside their health plans’ networks. The Attorney General’s office reached settlement agreements with the various health insurance companies that do business in New York State; these agreements focused on bringing fairness and transparency to the out-of-network reimbursement system. While the investigation took place in New York, the settlement had national implications.
FAIR Health was created as part of this settlement. Our mandate was to create and maintain a new database of charge data for healthcare procedures, and to offer consumers tools to make it easier to estimate out-of-network expenses. FAIR Health launched a free website to give consumers estimates of common charges for specific medical and dental services in their geographic areas. And, insurers nationwide now use FAIR Health data to help determine reimbursement rates for out-of-network claims.
- What is the purpose of FAIR Health and how is it unique?
FAIR Health aims to promote transparency in healthcare costs and health insurance information through comprehensive data products and consumer resources. As an independent, unbiased source of healthcare cost information, FAIR Health serves a wide range of audiences in the healthcare and insurance sphere: payors, healthcare professionals, consumers and researchers.
- Where does FAIR Health get its data?
FAIR Health obtains its data from health plans, insurance carriers and third-party administrators (TPAs). Approximately 80 companies nationwide currently participate in the data contribution program providing data for over 126 million covered lives. See more about the FAIR Health Data Contribution Program.
- Who advises the work of FAIR Health?
Ongoing counsel and guidance in the realization of FAIR Health’s mission are provided by a number of stakeholder groups, below:
- What is in the database?
The FAIR Health database is made up of de-identified data from billions of healthcare claims submitted to health insurers across the nation.
- How many claims are in the database? How many covered lives are served?
The FAIR Health Database includes 15 billion billed procedures nationwide from healthcare payors that collectively cover over 126 million lives in the private healthcare system.
- How do you protect the privacy of patients and providers?
The claims data submitted by payors are “de-identified” before they are sent to FAIR Health. To maintain privacy, claims in the database do not include information that can identify individuals.
- How was the database created?
In January 2009, then-New York Attorney General Andrew Cuomo announced the settlement of an investigation into the method used by certain health insurers to determine reimbursements for patients who receive care from out-of-network providers. The investigation found that there were potential conflicts of interest because the database used by many health insurers nationwide to help establish reimbursement rates was owned by Ingenix, a wholly-owned subsidiary of UnitedHealth Group. The settlement agreement reached with 12 health insurers doing business in New York focused on bringing fairness and transparency to the out-of-network reimbursement system by creating a non-industry, independent database to be run by a not-for-profit organization. FAIR Health was formed to own and operate the database.
- Who maintains the data?
FAIR Health owns and manages the database and works with advisors from the academic and research community to refine the statistical methodologies employed to enhance the value of FAIR Health products.
- Who helps FAIR Health analyze and organize the claims data that it collects?
FAIR Health’s expert staff works with a team of research universities known as the Upstate Health Research Network (UHRN) to examine the data and recommend and review potential changes. This team includes some of the most respected authorities in healthcare policy, medicine, economics and statistics from across the country. Led by Syracuse University, the UHRN includes researchers from Cornell University, University of Rochester, University at Albany (SUNY), University at Buffalo (SUNY), and SUNY Upstate. The University of Illinois, Indiana University, University of Colorado Denver and Arizona State University joined the UHRN as adjunct research institutions.
- How is the FAIR Health database validated?
FAIR Health has developed rigorous quality assurance processes to validate data before accepting the data into the database. Each data submission is subjected to a series of edit checks to help prevent flawed data from entering the database. For example, FAIR Health identifies and quarantines claims data with invalid dates of service or invalid zip codes. If data fail to pass the edit checks, FAIR Health will contact the data contributor to address the source of any errors or concerns.
- How does FAIR Health make its data available?
FAIR Health distributes the data from its database in the form of product modules and custom analytics, which are licensed for a fee to health insurance payors, providers and other customers. Each data product module contains benchmarks for procedures and services within a particular category (such as Medical/Surgical, Dental, Anesthesia, Outpatient, etc.), based on contributed data and calculated using a methodology developed with the Upstate Health Research Network. In mid-2012, FAIR Health plans to introduce a research support platform and a healthcare provider website to facilitate distribution of data to healthcare professionals and the research community.
FAIR Health also makes its data available to consumers through a free website at www.fairhealthconsumer.org. Employers, health plans, unions, associations and other organizations are invited to build awareness of FAIR Health consumer resources by making free links and materials available to their employees/members. Organizations may license customized versions of FAIR Health consumer tools.
- What geographic areas are covered by the FAIR Health database?
The FAIR Health database includes billed charges from all geographic areas in the United States. FAIR Health does not have billed charges from outside the United States.
- How frequently are data in the products refreshed?
FAIR Health data products are updated at least twice a year to reflect new data collected and included in the FAIR Health Database. Product modules provide 12 months of data updated for each release. The cutoff date for data to be included in a module is three months prior to the release of each module.
- How are FAIR Health products used?
Organizations and professionals use FAIR Health data in a variety of ways. Visit Data Products for some examples.
- What are “usual and customary rates”?
Usual, customary and reasonable rates, or UCR, are set by many insurers as part of their out-of-network reimbursement strategy. Many health plans reimburse out-of-network services as a percentage (e.g., 70%) of UCR. Insurers may establish UCR rates at any level they choose and often use benchmark data to assist in this determination.
- Does FAIR Health set “usual and customary rates” for insurers?
No. FAIR Health offers benchmarking data to assist insurers in establishing usual and customary rates (UCR) for out-of-network reimbursement. FAIR Health does not set UCR rates or out-of-network reimbursement amounts; these determinations are made by insurers themselves. FAIR Health data are intended to inform those decisions.
- Who can license FAIR Health data?
FAIR Health licenses data to many types of organizations, including payors, third-party administrators (TPAs), government agencies, healthcare providers/facilities and researchers.
- What are the benefits of contributing data to the FAIR Health database?
Clients rely on the FAIR Health database to provide a rich array of geographically specific charge data. To maximize the value of the database and the data products it supports, FAIR Health maintains a data contribution program. Eligible contributors are urged to participate – a large data pool not only adds value to the data products available for license, but also enhances the free FH Consumer Cost Lookup available at www.fairhealthconsumer.org.
- Who can submit data?
To ensure that claims data are not duplicated within the database, participation in the FAIR Health data contribution program is limited to eligible contributors:- Health plans
- Insurance carriers
- Third party administrators (TPAs)
Contributors must currently license FAIR Health data products.
Approximately 80 companies nationwide currently participate in the data contribution program providing data for over 126 million covered lives.
FAIR Health regrets that it cannot accept claims submissions from providers. Due to the volume of data contributions from the payor community, there is a high probability that provider claims will not be unique and will result in duplication of data within the database.
- What are the guidelines for submitting data?
To ensure the quality and integrity of the database, FAIR Health offers the following guidelines for submitting charge data:- Data must include all billed charges for the contribution period,
- Data cannot be manipulated, supplemented or pre-edited (except for de-identification),
- Submitted charges must be non-discounted fees-for-service as billed by the provider (for example, Medicare balance billing charges are not accepted),
- Data must not contain any duplication within or across submissions,
- Claims data must not have been previously submitted,
- Zip codes must reflect where the actual service was performed or the physical location of the provider (not the provider’s billing zip code), and
- Data fields must be consistent with the data field definitions provided by FAIR Health.
Participants in the data contribution program must attest that submissions comply with these guidelines. Only data that are accepted into the program will be eligible for credits applied to renewal licensing fees.
- How can an organization find out more about submitting data to FAIR Health?
For more information or to enroll in the data contribution program contact FAIR Health online or call FH Support at (800) 373-3073 today!
- Are there incentives for submitting data to FAIR Health?
As an incentive to contribute data, FAIR Health offers credits, that reduce data licensing fees, to qualified data contributors. Data credits will offset license fees for the next renewal term after the data are accepted by FAIR Health.
Participants in the data contribution program can earn credits of up to 75% of licensing fees. Contributors with one million or more covered lives have the opportunity to offset renewal licensing fees by an even greater percentage.
Credits are based on the number of accepted claims and vary depending on the type of data provided and whether optional fields are supplied in addition to the mandatory fields required for participation.
- How do I submit data files to FAIR Health?
FAIR Health has worked with nearly 100 organizations to establish and test data contribution file transfers and to monitor monthly data contribution feeds. This experience has enabled FAIR Health to streamline the program and get customers up and running and earning data credits quickly and easily. For more information or to enroll in the data contribution program contact FAIR Health online or call FH Support at (800) 373-3073 today!
- What data products/modules are available?
FAIR Health licenses data products in two series: FH® Benchmarks and FH® RV Benchmarks. Each of the following data modules is available in both the FH Benchmarks series and the FH RV Benchmarks series and includes benchmark charge data for a rolling 12-month period ending three months prior to the release of the module. The FH RV benchmark series contains derived data based on relative values and the FH Benchmarks modules generally contain actual data. FAIR Health licenses the following data product modules:
- Medical/Surgical
- Dental
- Anesthesia
- Inpatient Facility
- Outpatient Facility
- Healthcare Common Procedure Coding System (HCPCS)
- Allowed Medical
Custom analytics and derivative cuts of data modules are available and can be configured to customer specifications.
For complete information about FAIR Heath data products, visit Product Information.
- Can I license data for select procedure codes or geographic areas?
Yes. FAIR Health will work with organizations to tailor and array data based on custom specifications. For more information, contact FH Support at (800) 373-3073 or e-mail FHSupport@fairhealthus.org.
- How do the data presented on the consumer website differ from data available to subscribers/licensees?
The consumer tools available at www.fairhealthconsumer.org provide cost estimates based on actual benchmark data; licensees have the option to license modules with actual data or derived data based on relative values.
- How does FAIR Health validate its data products?
FAIR Health has established a thorough process to help ensure the integrity of the data in its database and products. Data are carefully validated before being accepted through the FAIR Health data contribution program. Part of this process involves testing the data with statistical algorithms to ensure that clear errors are eliminated.
Each release of FAIR Health products is examined by in-house experts in statistics and technology and audited and validated through a comprehensive external review process.
- What happens if there is an insufficient number of claims for a procedure in a particular geozip to determine reliable benchmarks?
When there is an insufficient number of claims for a procedure in a particular geozip, FAIR Health will employ a blended methodology. Customers may choose to license modules with some benchmarks determined by a blended methodology or to license the data as a “stat” file. In the “stat” format, data fields are left blank when there is an insufficient number of claims for a given procedure/geozip combination.
- How does FAIR Health handle outliers that may represent invalid charges?
FAIR Health employs an extreme outlier methodology to detect and remove billed services that may represent invalid charge data. We currently use the Median Absolute Deviation (MAD) method to identify and remove high and low outliers from the database. The MAD algorithm is an accepted statistical approach to identify extreme changes in data that do not conform to a normal distribution.
- How does FAIR Health handle small cells/low frequency data?
To address small cells, i.e., low frequency data, FAIR Health employs a small cell methodology that is continually tested and refined.
- Are FAIR Health data available to the public?
Yes, FAIR Health maintains a free website, www.fairhealthconsumer.org, where consumers can obtain cost estimates based on actual charge data by using the medical and dental cost lookup tools on the site.
- What information is available to the public?
FAIR Health provides benchmark data for medical and dental procedures on its consumer website, www.fairhealthconsumer.org. These cost estimates are based on actual benchmark data; derived charge data, which are available in the FH RV Benchmarks products, are not available on the consumer website.
- How can I find FAIR Health consumer tools?
FAIR Health consumer tools are available at www.fairhealthconsumer.org. Organizations are encouraged to make FAIR Health resources available to their employees/members by placing free links from organization websites to the FAIR Health consumer site. Visit the Resource Center to download free tools for use with employees, plan participants and union/association members.
- Can I link to the FAIR Health consumer website?
Yes, FAIR Health provides free pre-formatted links, which can be easily uploaded to an organization’s website. Visit the Resource Center to download these links and other consumer-oriented materials.
- Can FAIR Health consumer tools be customized?
Yes, FAIR Health consumer tools can be customized. Fees may apply. For more information, call FH Support at (800) 373-3073 or e-mail fhsupport@fairhealthus.org.
- Can we integrate FAIR Health data into our benefits site?
Yes, FAIR Health data can be licensed and integrated into benefits sites. Fees apply. For more information, call FH Support at (800) 373-3073 or e-mail fhsupport@fairhealthus.org.
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