Who is FAIR Health?
FAIR Health is an 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.
Why was FAIR Health created?
We were 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. We have launched this free website to give consumers estimates of common charges for specific medical and dental services in their geographic area. And
insurers nationwide now use our data to help determine reimbursement rates for out-of-network claims.
Is FAIR Health only relevant in New York?
No. Our
FH Consumer Cost Lookup has medical and dental cost data for every zip code in the United States, and we license our data products to insurers across the country for their use in establishing out-of-network reimbursement policies.
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. We do not set UCR rates or out-of-network reimbursement amounts; these determinations are made by insurers themselves. The FAIR Health data are intended to inform those decisions.
Who helps FAIR Health analyze and organize its claims data?
A team of research universities known as the Upstate Health Research Network (UHRN) advises FAIR Health on the best methods for analyzing its claims data. This team includes experts in healthcare policy, medicine, economics, and statistics from around New York State and across the country. Learn more about the UHRN
here. FAIR Health is also advised by a
Scientific Advisory Board of respected outside researchers to review our methods and products. Lastly, the development of our database and consumer website are informed on an ongoing basis by input from the many stakeholders interested in our work. These include consumer and patient advocacy groups, healthcare providers, health and dental plans, policymakers, actuaries, and state and federal officials.
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How did FAIR Health create its claims database?
As part of a settlement agreement reached between the New York State Attorney General’s Office and Ingenix, Inc., FAIR Health received millions of de-identified healthcare claims that healthcare providers nationally had submitted to health insurers. FAIR Health his since expanded that database, and currently receives de-identified healthcare claims data from insurers nationwide. These data are part of the massive database that is owned and overseen by FAIR Health. Learn more
here.
Does FAIR Health work with independent auditors to ensure the accuracy of its claims data?
Yes. We work with independent auditors to continually refine our data using five processes:
1)
Claims Submission Review: Working with
Emdeon, a leading provider of revenue and payment cycle management solutions with extensive experience working with health insurers, we carefully assess the claims data submitted by insurers and compare it to Emdeon’s database of provider claims.
2)
On-Site Auditing Program: Any major difference between our database and Emdeon’s can trigger an audit.
IPRO, a not-for-profit organization with over 25 years’ experience in assessing healthcare and performance improvement, then reviews the data as necessary to understand why the rates are different, and recommend action steps.
3)
Quality Assurance for Claims: We continually work with IPRO to create standards to make sure that the data submitted to us is complete and accurate before it enters our database. This also helps us identify areas for improvement and ways we can improve our data collection.
4)
Quality Assurance for Data: IPRO also serves as external eyes into our development process to help ensure that changes to our database production programs are made without error and do what they are intended to do.
5)
Assessment of Data Coverage: Going forward, we will work with Emdeon to identify regions in the U.S. that are under-represented in our claims data, and develop strategies to ensure appropriate geographic representation.
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FH Consumer Cost Lookup
How can the FH Consumer Cost Lookup help me with planning for my healthcare expenses?
The
FH Consumer Cost Lookup will give you an estimate of the bill you might receive from your health or dental provider, as well as estimate how much of that bill your insurer might reimburse if you receive the services out-of-network. You can now estimate how much you will have to spend
before you decide whether to go out of your insurer’s network for a medical or dental procedure or service. Learn more
here.
What information is contained on the FH Consumer Cost Lookup?
The
FH Consumer Cost Lookup features the
FH Medical Cost Lookup and
FH Dental Cost Lookup tools, which provide cost estimates for specific medical or dental services that you enter on the site. These tools will also estimate how much your health insurer will reimburse you if you receive a particular service out-of-network, and will give you information specific to the geographic region where you receive your care. The
FH Consumer Cost Lookup also offers educational videos about health insurance reimbursement, links to healthcare resources, and a glossary of commonly used reimbursement terms.
Understanding Your Medical Cost Estimate
How can I learn how to use the FH Medical Cost Lookup?
The best way to learn about our tool is to view our
how-to-video. We have also included lots of tips and helpful hints within the tool itself. You can also contact our consumer information line at
1-888-288-1441, or e-mail us at
info@fairhealthconsumer.org.
Is the medical cost estimate that I receive from the FH Consumer Cost Lookup the exact amount that I will owe for out-of-network medical services?
Not necessarily. The medical charge data that you obtain from this site are estimates of what you may be responsible for paying for medical procedures and services received out-of-network. While these estimates are based on the extensive data we have related to the fees that are charged by providers in your area, other factors may influence the amount that you will have to pay for out-of-network healthcare services.
Please note that FAIR Health does not determine, develop or establish appropriate fees or reimbursement levels for any medical procedure or service. All of our estimates are provided for informational purposes only.
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Why is the medical cost estimate that I received from this website different from what I am being asked to pay for a medical procedure I received out-of-network?
A number of factors may influence the amount that you will be asked to pay for a medical procedure received out-of-network. Your actual costs may vary depending on factors specific to your provider or health plan. Read more about this below.
What are some health plan-related factors that can influence my out-of-pocket costs for medical care?
The design of your health plan may influence how much you will be asked to pay for out-of-network care. For example, you may need to pay an annual deductible before your insurer will begin to reimburse you for care that you receive. Your insurer may also reimburse your out-of-network expenses according to a formula that is different from the one you used on our website when you estimated the charge. Our website allows you to change some of the variables included in the reimbursement formula to obtain a more accurate estimate. To do so, you will need to know the details of your health insurance policy. Some ways of getting these details are below.
How can I obtain more information to help me better determine my out-of-network medical expenses?
You can obtain more detailed information to help you better determine your out-of-network medical expenses by asking your employer or insurance company.
Ask Your Employer
Your employer's benefits administrator should be able to give (or find) the coverage type and reimbursement percentile you need to utilize this website to its full potential.
Contact member services at your insurance company
Most insurance companies have member areas of their websites, online question forms, and in some cases, opportunities to conduct live chats with customer service representatives. You may also call the phone number listed on the back of your insurance card.
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Understanding Your Dental Cost Estimate
How can I learn to use the FH Dental Cost Lookup?
The best way to learn about the
FH Dental Cost Lookup is to view our
how-to video. We have also included lots of tips and helpful hints within the tool itself. You can also contact our consumer information line at
1-888-288-1441, or e-mail us at
info@fairhealthconsumer.org.
Is the dental cost estimate that I receive from the FH Consumer Cost Lookup the exact amount that I will owe for out-of-network dental services?
Not necessarily. The dental charge data that you obtain from this site are estimates of what you may be responsible for paying for dental procedures and services that you receive from an out-of-network healthcare provider. While these estimates are based on the extensive data we have related to the fees that are charged by providers in your area, other factors may influence the amount that you will have to pay for out-of-network healthcare services.
Please note that FAIR Health does not determine, develop or establish appropriate fees or reimbursement levels for any dental procedure or service. All of our estimates are provided for informational purposes only.
Why is the cost estimate that I received from this website different from what I am being asked to pay for a dental procedure received out-of-network?
A number of factors may influence the amount that you will be asked to pay out-of-pocket for a dental procedure received out-of-network. Your actual costs may vary depending on factors specific to your provider or insurance plan. Read more about this below.
What are some provider-related factors that may influence my out-of-pocket dental costs?
For various reasons, different providers may charge different amounts for the same service. For example, a provider’s fees may be based on the number of years he or she has been in practice, or whether he or she is board-certified or has received other special training or designations. As a result, the provider you choose to see may bill more or less than our site’s cost estimate for your geographic area, and this will impact both the amount of reimbursement you receive from your health plan and the amount you owe your provider.
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What are some dental plan-related factors that can influence my out-of-pocket costs for medical care?
The design of your dental plan may influence how much you will be asked to pay for out-of-network care. For example, you may need to pay an annual deductible before your insurer will begin to reimburse you for care that you receive. Your insurer may also reimburse your out-of-network expenses according to a formula that is different from the one we have built into our website. Our website allows you to change some of the variables included in the reimbursement formula to obtain a more accurate estimate. To do so, you will need to know the details of your health insurance policy. Some ways of getting these details are below.
Most dental plans have age and frequency limits on dental services. For example, crowns may have a replacement limit of 60 months. If your crown has been in your mouth less than 60 months, it may not be eligible for coverage. Other services may have similar limits. You should check with your carrier to understand the limits and exclusions of your dental plan.
How can I obtain more information to help me better determine my dental out-of-network expenses?
You can obtain more detailed information to help you better determine your out-of-network expenses by asking your employer or insurance company.
Ask Your Employer
Your employer's benefits administrator should be able to give (or find) the coverage type and reimbursement percentile you need to utilize this website to its full potential.
Contact member services at your insurance company
Most insurance companies have member areas of their websites, online question forms, and in some cases, opportunities to conduct live chats with customer service representatives. You may also call the phone number listed on the back of your insurance card. For a list of dental plans, click
here
Health and Dental Coverage
My current health plan does not include dental coverage. Where can I go to find more information about dental plans?
Learn more by consulting the FAIR Health guide on
Dental Plans: What You Need to Know
I visited an in-network preferred hospital, but the healthcare provider who provided my care was not in my insurer’s network. Now I'm stuck with a huge bill. What can I do?
Unfortunately, this experience is not uncommon. Please consult the FAIR Health guide on
Appealing a Reimbursement Decision. You may also visit the
National Association of Insurance Commissioners and locate the website for your state’s department of insurance on the States and Jurisdiction Map.
What do I do if my health insurer denied a claim that I submitted for out-of-network care?
You have the right to appeal your insurer’s decision to deny your claim. For more information on how to do this, visit
Appealing a Reimbursement Decision.
How can I find out if my health plan is using FAIR Health data to determine reimbursement rates?
You may choose to contact your health plan to ask them this information. Most insurance companies have member areas of their websites, online question forms, and in some cases, opportunities to conduct live chats with customer service representatives. You may also call the phone number listed on the back of your insurance card.
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