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.