THE DEFINING VEHICLE FOR AN ALL PAYER CLAIMS DATABASE

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1 THE DEFINING VEHICLE FOR AN ALL PAYER CLAIMS DATABASE

2 Asuccessful All Payer Claims Database (APCD) must be able to collect, validate, aggregate and manage vast, constantly increasing amounts of healthcare claims data. It needs to accept data from disparate sources seamlessly. It must provide access to a wide variety of data fields across multiple service types. It needs to offer platforms that make the data accessible and useful to a broad range of users, including policymakers, government officials, health services researchers, economists, health plans, practitioners and consumers. It must guarantee that the personal information of patients, practitioners and contributors is private and secure. And its methodologies must ensure that duplicate data are eliminated, and that the data it maintains are transparent and reliable. In short, it needs to replicate what FAIR Health does every day for thousands of consumers and clients. 2

3 security, its dedicated and highly qualified staff and its exceptional history as an organization founded expressly to bring transparency and integrity to the healthcare landscape. Proud of Our History, Committed to Our Mandate FAIR Health was established in October 2009 as part of the settlement of an investigation by New York State into the health insurance industry s practice of determining out-of-network reimbursement based on a database that it compiled and controlled. FAIR Health was formed to manage, improve and expand the database and to enhance its transparency, reliability and accessibility. FAIR Health was charged with providing a diverse range of healthcare stakeholders with reliable products and services, including: founded expressly to bring transparency and integrity to the healthcare landscape. WHO WE ARE A national, independent, not-for-profit corporation whose mission is to bring fairness and transparency to healthcare costs and health insurance information, FAIR Health is uniquely qualified to deliver APCD services. Those qualifications are evidenced by the unmatched volume of commercial claims data FAIR Health receives and maintains, the vast number of individuals, organizations and governmental bodies nationwide who rely on FAIR Health as an unbiased data source, the participation of diverse stakeholders in an advisory capacity to ensure transparency and product utility, its leading-edge protocols for ensuring data quality and An independent database of healthcare claims information contributed by some of the largest health insurers and other payers nationwide and developed with the support of independent academic experts. A free website to educate consumers about the cost of care in their geographic area and the health insurance reimbursement process. A research platform for policymakers, government officials and academics. With the guidance of our advisors, including leading experts in healthcare policy, medicine, economics and statistics, FAIR Health delivers on its commitment to its broad array of clients, and in the process provides the strongest possible foundation to help inform healthcare decisions and business operations. FAIR Health is, in effect, a multi-payer claims database with voluntary contributions and a data repository of over 16 billion medical and dental claims from all geographic regions of the country, reflecting the claims experience of over 140 million lives covered by private health insurers. 3

4 WHAT WE OFFER FAIR Health s unique qualifications fulfill and surpass the requirements for an APCD. Scalability. FAIR Health s database currently houses accessible records for more than 16 billion claims the largest private claims repository in the country. Our ability to manage your claims collection, regardless of volume, is without question. Seamless data integration. Currently receiving claims information from more than 60 contributors, including some of the largest health insurers and third party administrators nationwide, on behalf of over 140 million covered lives, FAIR Health has a proven ability to accept data from multiple sources, aggregate it, validate it and organize it into multiple formats used successfully by a variety of stakeholders. Regional geographical specificity. We organize our data into 491 distinct geographic regions all 50 states, the District of Columbia, Puerto Rico and the Virgin Islands. Shaped by expert guidance. We subject data to robust auditing and validation processes that employ methodologies developed by independent experts in healthcare economics and statistics. Proven systems and protocols to ensure data quality. Performed at several stages during the claims data collection, validation, aggregation and production cycles, our quality assurance processes subject claims data to intense scrutiny and tests that standardize data from disparate contributors, identify missing data and exclude erroneous data. De-identified data. We ensure the removal of all patient, practitioner, contributor and other identifying information from the claims we receive. Transparent and useful. The transparency and utility of our data are assured by the over sight of our Advisory Boards, which include nationally recognized healthcare industry and academic leaders. In-house data security and data management process control. FAIR Health s data management operations are managed entirely by specially trained FAIR Health employees, with particular attention paid to data privacy and security requirements. We can sum up FAIR Health s qualifications in a word: experience. We have in-depth, unmatched knowledge of how to create, maintain, secure and increase vast claims repositories, proven strategies for addressing the difficulties inherent in receiving large datasets from a multitude of contributors and capabilities for developing tools and formats that enable stakeholders to extract from those databases the precise information they need. 4

5 and dental practitioners, and web-based tools that utilize application programming interface (API) technology to populate customized and innovative data dashboards for policymaking, strategic planning and other business decisions. Support for Initial APCD Use Cases more than 16 billion claims for medical and dental procedures representing over 140 million covered lives from 491 distinct geographic regions Custom Tools to Provide Consumers and Stakeholders Meaningful Access to Data FAIR Health also provides data access for consumers, practitioners, administrators, researchers and other healthcare stakeholders in a variety of formats that are meaningful and unique to them. For example, FAIR Health s claims data serve as the foundation for its free, award-winning consumer website (fairhealthconsumer.org) that enables patients to research the cost of specific healthcare services in their geographic area and provides them with additional essential information they need to make informed decisions about their healthcare. We also offer an online portal that features business planning tools for medical As a nation-wide organization with a repository holding more than 16 billion claims for medical and dental procedures representing over 140 million covered lives from 491 distinct geographic regions, we may already have much of your state s recent claims history in our database. This would enable us to work with you to create a custom dataset or frame a pilot project to demonstrate the potential value of an APCD including public health planning, consumer education, premium rate review, benefit utilization trend analysis, and more. We can drill down into your claims data to create customized analyses, including the following: Custom geographic regions and geozip combinations. Create datasets focused on the medical or dental markets you specify for example, comparing your state to other states in your region. Examine trends in those markets to analyze how they have changed over time. Custom groupings of procedure codes. View charge benchmarks and utilization data for only the procedures that are of interest to your constituents. Specify the range of percentiles and time periods that are relevant to your needs. Analysis of service utilization patterns. Understand geographic patterns in the utilization of specific services and see how the frequency with which those services have been performed has changed over time. Data for specific time periods. Develop custom datasets to track changes in billing and utilization over the time periods you wish to study, from six months to 10 years. 5

6 WHY FAIR HEALTH IS YOUR BEST CHOICE Help in Avoiding Pitfalls It is important that you choose a health data management organization that will be able to support your needs for the long-term long after your APCD is implemented. Other organizations can collect data. The key is to choose one that can organize those data, extract the pertinent information and make it work for you. FAIR Health is providing those services today for hundreds of clients whose needs are similar to yours. Will other data management organizations be equipped to handle an increase in your claims volume? Will they be able to accept data from multiple IT systems in multiple formats without causing disruption? FAIR Health has the unique experience of collecting, validating and aggregating over 16 billion claims contributed by more than 60 sources and seamlessly incorporating such data into our repository convincing evidence of our capacity and performance. Not-for-Profit, Independent and Completely In Line with CMS Requirements FAIR Health combines the integrity and values of a not-for-profit organization with the vision and technological expertise of a cutting-edge health data management organization. Our corporate structure and business direction are determined by a conflict-free, non-compensated Board of Directors. Our revenue is re-invested to improve the services we provide, supporting our mission to deliver transparent healthcare cost information at the most usable level for all healthcare stakeholders. As a clear indication of the effectiveness of FAIR Health s approach to satisfying our mission, our structure, product offerings, database configuration, methodologies, consumer cost lookup tools, core strategic focus and overall organizational blueprint were the inspiration for the model CMS Data Center specifications laid out in the Affordable Care Act. A Sustainable APCD Model Ready to Meet Future Challenges FAIR Health offers its clients a proven model for APCD sustainability. In some cases, local APCD initiatives are built solely on initial funding that disappears from budgets after the project is up and running. While other vendors simply offer data collection and aggregation services, FAIR Health offers expertise and insights from our experience in running our own multi-payer claims database. Our business model keeps the data fresh and valuable so that our clients can work with us to repurpose it as a self-sustaining revenue stream. As your APCD grows, your needs will change over time. We will be there to help you address them by continuing to offer versatile, powerful, next-generation data management tools customized for you. CONTACT US We would welcome the opportunity to work with you to evaluate your organization s needs and establish the particular datasets, customized analytics and program protocols, processes and features that will provide the data you need in the format most helpful to you. We are committed to delivering and managing an APCD with the capabilities and specifications that precisely address your requirements. info@fairhealth.org n FAIR (3247) FAIR Health, Inc. 575 Fifth Avenue, 22nd Floor, New York, NY n n Copyright 2014, FAIR Health, Inc. All rights reserved. 6