NORC researchers reviewed available information related to FAIR Health, three other national databases and 15 state APCDs to determine the most reliable source of data when benchmarking out-of-network physician reimbursements at in-network facilities. The criteria on which NORC evaluated the databases, which were developed in consultation with Physicians for Fair Coverage, included:
- The size and scope of the database
- Availability of both allowed and billed charges
- Availability for benchmarking
- Cost of licensing the data
- Overall independence of the vendors
This analysis showed that FAIR Health met the most criteria and indicated FAIR Health is an important potential source of data. An important differentiator is that FAIR Health licenses their data for out-of-network benchmarking purposes unlike most other national data sources.
This independent research showed that FAIR Health not only has an exceptionally large and geographically representative database, but also due to the ability to search data in a geographical zip code, offers deep local comparisons of physician charges. This conclusion follows, in part, from the following attributes of FAIR Health:
- A national dataset with over 150 million covered lives
- Contains both commercial and Medicare claims
- Includes allowed and billed charges
- Is easily accessible data and moderately priced
- Transparency is its primary business
For the purpose of identifying a standard benchmark, outlined by Physicians for Fair Coverage in the study, NORC’s review found that using data from a national vendor had advantages over state APCDs. NORC found that APCD data and access processes are not uniform across states, and because of these limitations, rendering a nation-wide standard and process for analysis of claims and costs associated with the establishment and maintenance of the databases very difficult. Moreover, the recent Supreme Court decision in Gobielle v. Liberty Mutual Insurance Company means that states cannot require ERISA-regulated self-funded plans to report data, making it more difficult to apply benchmarks based on these data.
“Our review found that FAIR Health offers a useful and localized data set that can be utilized to help inform policymaking with respect to how to reimburse for medical services provided by out-of-network physicians,” said Jon Gabel, NORC’s lead researcher.
“Legislators across the country are recognizing that surprise insurance gaps are leaving patients exposed,” said Michele Kimball, CEO, Physicians for Fair Coverage. “As they work to close these gaps caused by insurers narrowing physician networks, this NORC analysis demonstrates that using the FAIR Health database to better understand for out-of-network payments is the more comprehensive, transparent…