Download Outpatient Facility Benchmarks

Outpatient Facility
Benchmarks
A Rich Source of Data for Decision Making
Each Outpatient Facility
module is based on
over 600 million
procedures billed during
a 12-month period.
A rich, reliable source of claims data is the key to success when managing risk,
administering provider networks, adjudicating out-of-network claims, designing
benefits and analyzing market trends. Informing strategic decisions with robust
data can enhance initiatives and promote cost efficiencies, resulting in returns
that far outweigh the investment.
USE FAIR HEALTH CHARGE BENCHMARKS TO:
Support development of fee schedules.
Adjudicate out-of-network claims.
Facilitate discussions with network providers and hospital systems.
Build member transparency and educational tools.
Evaluate alternative reimbursement models
(e.g., Accountable Care Organizations).
Support eligibility as a “qualified health plan” on exchanges.
Analyze network and pricing gaps.
Review claims patterns.
Shape strategic initiatives.
FH® Outpatient Facility Benchmarks
The Outpatient Facility module provides charge data for Category I CPT®
codes for services offered in an outpatient setting. Professional services, with
the exception of physical therapy, are not included in the Outpatient Facility
module. Benchmarks are also available organized by International Classification
of Diseases (ICD) codes, which are cross-referenced to CPT codes. Benchmarks
are derived by applying a relative value and conversion factor methodology to
charge data. The benchmarks are arrayed by percentile and geozip.
FAIR Health Outpatient Facility Benchmarks modules are based on billed
charges from the Centers for Medicare & Medicaid Services (CMS) Outpatient
Standard Analytical File (OPSAF) data.
Geozips are geographic areas, generally defined by the first three digits of a zip
code. Classifying charges by geozips ensures that the benchmarks are relevant to a
specific area. Within each geozip, the data are organized into percentiles reflecting
the position of the charges along the spectrum of billed amounts, from lowest to
highest. For example, 80 percent of the
billed amounts in the FAIR Health database
for a specific procedure code/geozip
To learn more, contact
combination are equal to or less than the
FAIR Health today!
charge shown in the 80th percentile for
the combination; 20 percent of the data
are equal to or greater than this amount.
855.301.FAIR (3247)
[email protected]
www.fairhealth.org
OUTPATIENT FACILITY BENCHMARKS
Sample Benchmark Data
Each Outpatient Facility module is based on over 600 million procedures billed during a 12-month period.
The following is an example of the data available for over 9,000 CPT codes in 491 distinct geozips across the country.
Geozip Procedure
Code
631
45383
Description
Mean
(Avg.)
Percentiles
50
Lesion
$3,814 $3,253
Removal
Colonoscopy
60
70
75
80
85
$3,590 $4,043 $4,178 $4,270 $4,427
90
95
$4,827
$5,858
Claims data undergo a rigorous validation process before they are accepted into the FAIR Health database on which
modules are based.
The FH Online Query Tool may be licensed to provide easy access to benchmark data.
FAIR Health offers additional data resources to streamline analysis for other types of claims:
Medical Surgical
Benchmarks for professional service charges for
more than 9,000 evaluation and management,
medical, surgical, radiology, laboratory and pathology
procedure codes facilitate analysis and adjudication
of medical claims.
Anesthesia
Data for over 9,000 anesthesia and surgical
procedure codes plus base units, physical status
modifiers and qualifying circumstances facilitate cost
calculations for reported anesthesia times.
Dental
Benchmark charges for over 500 dental procedure
codes facilitate analysis and adjudication of dental
claims.
Inpatient Facility
Derived per diem and total charges for more than 750
Diagnosis-Related Groups (DRGs) categorize services
with similar hospital resource use.
HCPCS
(Healthcare Common Procedure Coding System)
Charges are included for over 3,000 procedure codes
for ambulance services, durable medical equipment,
injectable drugs, prosthetics, orthotics and supplies
used outside a physician’s office.
Allowed Medical
Derived fees allowed by plans for professional charges
for more than 9,000 medical and surgical procedure
codes assist with pricing review and trend analysis.
Custom Analytics
Data analytics, customized to meet client specifications, can be used to address strategic and tactical initiatives.
Examples of custom analytics include data sets for specific locations or procedure codes, clinical treatment scenarios
or added dimensions such as claim modifiers, frequency of performed procedures and trending over time.
To learn more, contact FAIR Health today!
855.301.FAIR (3247) • [email protected]
© 2015, FAIR Health, Inc. All rights reserved.
CPT © 2014 American Medical Association (AMA). All rights reserved.