Surprise Billing Solutions from FAIR Health

Surprise Billing Solutions from FAIR Health

FAIR Health’s reliable and up‐to‐date data serve as an objective window into healthcare costs, and a valuable resource to assist health plans, providers and arbitrators in determining reimbursement amounts under surprise billing laws. FAIR Health serves as the official data source for several state surprise billing laws, and FAIR Health’s FH® NSA Reference File was specifically created to support compliance with the federal No Surprises Act.

Federal No Surprises Act

The FH NSA Reference File includes median, in-network allowed amounts for medical, HCPCS, anesthesia, outpatient facility and inpatient facility services. Values are provided by procedure code at geographic levels corresponding with the No Surprises Act regulations: individual Metropolitan Statistical Areas (MSAs), all MSAs in each state, all non-MSA areas in each state, all MSAs in each Census Division and all non-MSA areas in each Census Division. The data can be licensed for several uses including:

  • Qualifying Payment Amount (QPA) Calculations:Regulations implementing the NSA allow payors to use a third‐party database qualifying as an “eligible database” to establish a QPA when they have insufficient information to calculate a QPA using their own contracted rates. The FH NSA Reference File supports these needs, reporting the median of in‐network allowed amounts for the service in a geographic region.
  • Initial Payment Amounts: The data may inform plans’ selection of an initial payment amount to out-of-network providers, potentially reducing disputes and the need for arbitration.
  • Independent Dispute Resolution (IDR): Licensees may use the FH NSA Reference File in arbitration and dispute resolution under the No Surprises Act. In addition, FAIR Health publishes FH® Allowed Benchmarks—also based on commercial in-network allowed amounts—which include the median as well as a range of percentile values for in-network, commercial allowed amounts organized by geozip (a geographic area that typically corresponds to the first three digits of a zip code). FH Allowed Benchmarks and the FH NSA Reference File do not include any prohibited factors such as provider-billed charges, UCR or public payor rates.

FAIR Health is uniquely positioned to serve as an eligible third‐party database, as contemplated under the No Surprises Act:

  • Independent, not affiliated with, owned or controlled by a healthcare insurer or provider: FAIR Health is an independent nonprofit organization and is not affiliated with, or owned or controlled by, any health insurance issuer, healthcare provider, facility or provider of air ambulance services, and is not a member of the same controlled group as, or under common control with, any such entity.
  • Sufficient data reflecting in‐network amounts for the procedure in the relevant geographic area: FAIR Health holds the nation’s largest repository of private health claims data. The repository receives new claim records each year from group health plans and insurance issuers offering group and individual health insurance coverage, including claims from each of the 50 states; Washington, DC; Puerto Rico; and the US Virgin Islands. The FAIR Health database includes allowed amounts provided by commercial payors for services and items furnished by providers, facilities and providers of air ambulance services, organized by procedure code and geographic region.
  • Can distinguish amounts paid by commercial payors to participating providers from other data: The FAIR Health database clearly distinguishes commercial payors’ allowed amounts for participating providers and facilities from all other claims data, such as amounts billed by nonparticipating providers or facilities and amounts paid by public payors, including Medicare, Medicaid and others. The FH NSA Reference File and FH Allowed Benchmarks reflect commercial in-network rates only.

State Solutions

Many states have laws that protect patients from balance billing, and the scope of these protections varies. FAIR Health data serve as the independent, official data source for surprise billing laws in the following states:

  • Connecticut;
  • Georgia;
  • New Mexico;
  • New York; and
  • Texas.

Many organizations rely on FAIR Health benchmarks, including in states that do not specifically refer to FAIR Health in their statutes or regulations.

For more information, contact us by email at info@fairhealth.org or call us at 855-301-FAIR (3247), Monday through Friday, 9 am to 6 pm ET

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