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Frequently Asked Questions

FAIR Health

Consumer Tools Available through This Website

Looking Up Cost Estimates

Search Limits

Cost Estimates 

Consumer Rights and Assistance

New York State’s Emergency Medical Services and Surprise Bills Law

Licensing/Linking to this Website

Stay in Touch

 

 

FAIR Health 

What is FAIR Health?

FAIR Health is a national, independent, nonprofit organization. Our mission is to bring transparency and clarity to healthcare costs and health insurance information through consumer tools and resources, data products and research support. We use our database of billions of billed medical and dental services to power this award-winning, free website (www.fairhealthconsumer.org). Our website offers tools and educational resources that enable consumers to estimate and plan medical and dental expenses and to better understand the healthcare system. These tools also are available in Spanish at www.consumidor.fairhealth.org and on free mobile apps in English and Spanish through iTunes and Google Play.

 
FAIR Health serves all healthcare stakeholders, such as consumers, providers, payors, employers, researchers and policy makers. We also partner with leaders in the healthcare field to make sure our data and tools are the best that they can be. Learn more by visiting our company website at www.fairhealth.org.
 

Why was FAIR Health created?

FAIR Health was created 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 set reimbursement for patients who received care from out-of-network providers (doctors or health providers that do not contract with the patient’s health insurer). The Office of the Attorney General settled the case with health insurers that do business in New York State. The settlement agreements focused on bringing fairness and transparency to the out-of-network reimbursement system.

FAIR Health, which was created as part of this settlement, owns a database with charge data for billions of billed medical and dental services and procedures. We use our database to power this free website. The website’s cost lookup tools allow you to estimate your costs for medical and dental care. Insurers and other organizations across the country also use our data to help set reimbursement rates for out-of-network claims and for many other purposes.
 

Does FAIR Health set “usual, customary and reasonable" (UCR) rates for insurers?

No. FAIR Health offers benchmark charge data that some insurers may use to help inform their rates for out-of-network reimbursement. FAIR Health does not set UCR rates or out-of-network reimbursement rates for insurers—these decisions are made solely by insurers based on their internal policies.
 

Where does FAIR Health get its charge data? 

We have medical and dental charge data for all 50 states, Washington, DC, Puerto Rico and the US Virgin Islands. Through FAIR Health’s data contribution program, payors (insurers and administrators) from across the country contribute claims data to FAIR Health. These data reflect the full (undiscounted) charges that healthcare providers report to payors as part of the claims process. FAIR Health regularly adds new charge data to its database, which contains billions of billed procedures and services performed since 2002.
 

How does FAIR Health make sure that its data are reliable? 

FAIR Health’s in-house experts in statistics, economics and technology carefully follow a rigorous, multi-step process to check that the data are valid and reliable. Only valid data are added to the FAIR Health database. Learn more about our process here.

The medical and dental charge estimates on this website are based on the FAIR Health database and reflect 12 months of claims. The charge estimates are updated twice a year.
 

Who serves on the FAIR Health Board of Directors?

The FAIR Health Board of Directors comprises recognized leaders in the fields of medicine, healthcare policy, law, consumer advocacy, technology, education, medical research and business. They serve without compensation and adhere to rigorous conflict-of-interest policies.
 

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Consumer Website Tools Available through This Website

What will I find on this website?

Among other features, this website offers the FH Medical Cost Lookup and FH Dental Cost Lookup—online tools that allow you to estimate your out-of-pocket costs for medical and dental care. At this time, we have cost estimates for:

  • Thousands of medical and dental services (professional fees only);
  • Medical supplies (e.g., diabetes supplies, walkers, canes, vision supplies, hearing aids);
  • Anesthesia services; and
  • Ambulance rides
  • Charges for services done in a facility (e.g., hospital or ambulatory surgery center)

On this website, you also can find original articles explaining health insurance and reimbursement (FH Health Insurance 101), videos, links to external healthcare resources and a glossary of common insurance terms and healthcare procedures.
 

I have health insurance. Can I use the website to plan my healthcare costs?

Yes. If you are insured, use these tools to estimate your bill, how much your health or dental insurer will reimburse if you receive a service from an out-of-network provider and how much you may owe for that service. Use the cost lookup tools:

  • Before you decide whether to go out of network for care—to estimate the cost of that care. You also can estimate how much of the bill you will be asked to pay. 
     
  • After you get out-of-network care—to compare the cost estimate on the website with your Explanation of Benefits (EOB) or bills. If you have any questions, discuss them with your healthcare provider or health insurer.

If you stay in network for a service, your cost will be based on the “contracted rate”—what the insurer has agreed to pay the provider for that service. This website does not, at this time, provide contracted in-network rates. You can find out how much you will pay for an in-network service by reading information associated with your health benefits plan. You also can call your insurer using the member services number on the back of your ID card.
 

I don’t have health insurance. Can I use the website?

Yes. If you are uninsured, use the cost lookup tools to estimate your cost for medical and dental services. Select uninsured in Step 2 on the cost lookup tools and conduct a search. Then, use the cost estimate to discuss payment plans and negotiate with your healthcare providers. Note that the Affordable Care Act (ACA) requires all individuals (with some exceptions) to have health insurance or pay a penalty.
 

Do the medical cost estimates apply to people who are covered by Medicare, Medicaid or other government programs?

No. The cost estimates apply only to those who are covered by private insurance or who are uninsured. These cost estimates do not apply to those who are covered by government programs such as Medicare, Medicaid or Tricare. However, the information on the site can help you evaluate the benefits or extent of coverage of a Medicare Advantage Plan if you seek a plan that requires you to pay more for services outside of the plan’s network. 

Note: The FH Medicare Compare feature on the website is useful if you have a private insurer (i.e., non-government) that uses Medicare fees to set out-of-network reimbursement. This is not the same as being covered by Medicare.
 

I searched for a cost estimate and got "N/A." What does it mean?

If you see N/A (Not Available) after searching for a cost estimate, this means that our database does not contain enough information to give a cost estimate for the procedure code in the geographic area you searched.

 

I need to find a doctor or dentist. Can I find one on this website?

No. This website offers cost estimates for medical and dental procedures. It does not list doctors, dentists, hospitals, facilities or other providers. To find a provider:

  • If you are insured, visit your health insurer’s website for a list of in-network providers.
  • Refer to our Healthcare Resources section, under “Locate Healthcare Providers,” to find online tools that let you search for healthcare providers in your area.

New York Healthcare Online Shopping Tool (NY HOST) is a new healthcare planning tool we are developing for New York State residents to shop for and compare healthcare providers in their region. The tool will feature information on local physicians, hospitals and other healthcare providers who can provide some of the healthcare services or procedures found on this website. Learn more and sign up for updates on the development of this new tool, here.

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Looking Up Cost Estimates

What do I need to know in order to look up medical and dental costs on this website?

To look up medical and dental cost estimates on this website, you will need to know:

  • The ZIP code  or city and state where the service took place, or will take place, and
  • The service you’d like to search. Each service on the cost lookup tool is noted by a numeric medical (CPT®) or dental (CDT®) code, so it’s best to enter the specific code for a procedure. This will give you more reliable and accurate cost estimates. If you do not know the code, you can easily search through our directory of procedures available under Step 3 of the FH Medical Cost Lookup or FH Dental Cost Lookup to help guide you to the correct code
     

CPT© 2015 American Medical Association (AMA). All rights reserved.

The code on Dental Procedures and Nomenclature is published in Current Dental Terminology (CDT), American Dental Association (ADA). All rights reserved.

Where do I find the CPT or CDT code?

You can often find CPT and CDT codes on your medical or dental bill or  EOB. You can also ask your provider for the codes of a procedure or service you will receive, or have already received. 

Even if you do not know the CPT or CDT code for your procedure, you can use the cost lookup tools. Simply use the menu of procedures under Step 3 of the FH Medical Cost Lookup or FH Dental Cost Lookup. You will be able to select the procedure that is most similar to what you are looking for.
 

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Search Limits

Why does the website limit the number of searches I can conduct?

FAIR Health’s agreements with third parties place limits on the number of medical and dental searches that can be done on the site.

When looking up medical costs, consumers can search up to 20, medical codes each, per week. Entering a zip code and a medical procedure code (or choosing a procedure from the menu), counts as one search.

When looking up dental costs, consumers can conduct 10 searches, of up to five dental codes per search, each week. Consumers may enter up to five dental procedure codes per zip code or check up to five codes when using the menu of procedures in Step 3 of the FH Dental Cost Lookup. This counts as a single dental search.

Search limits are reset at the end of the weekly search period to enable consumers to estimate costs for additional codes.

The site at www.fairhealthconsumer.org is for consumer use. It is expected that in most cases, consumers will be able to meet their needs before reaching the search limit.

FAIR Health uses a computer’s IP address to track searches. If you use a computer whose IP address is shared throughout an office, library or other organization, you may reach the limit before you have personally conducted the maximum amount of searches.  

For information on licensing FAIR Health data for healthcare professionals and commercial businesses, contact info@fairhealth.org.
 

I am working on an appeal and need more searches, but have reached my limit. What can I do?

If you are working on an appeal, with a filing deadline before the search limit resets, e-mail us at consumer@fairhealth.org and explain your situation.
 

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Cost Estimates

How does FAIR Health create its cost estimates?

FAIR Health analyzes the nationwide data it collects and uses established statistical methods to create cost estimates for procedures by geozip. A geozip is a geographic area that generally includes zip codes that share the first three digits.

 

How often are the medical and dental cost estimates on the website updated? 

Medical and dental cost estimates are updated every 6 months (twice a year) and are based on 12 months of data.
 

Why is the medical or dental cost estimate on the website different from my bill for an out-of-network service?

What you are actually asked to pay for an out-of-network service depends on many factors. These include what your specific healthcare provider charges and your health benefits plan details.

  • Healthcare Professionals: Healthcare professionals set their own fees. A doctor’s fees may be based on the number of years he or she has been in practice, or whether he or she is a specialist, is board-certified, has completed particular training and other factors. Factors such as rent, salaries for office staff and malpractice insurance can also affect prices.  The healthcare provider you choose may bill more or less than the cost estimate on this site. This can impact both the amount your insurer will reimburse and how much you will be asked to pay.
     
  • Health Benefits Plan: The design of your insurer’s specific health benefits plan in which you are enrolled also may affect how much you pay for out-of-network care. For example, you may need to meet an annual deductible before your insurer will begin to reimburse for your care. This website allows you to estimate costs based on a traditional “UCR-based” reimbursement method. The website also allows you to estimate your costs if your insurer uses a Medicare-based formula for out-of-network reimbursement (select “Medicare-Based” at the top of the page where you see your cost estimate). To get the most accurate cost estimate, you will need to know the details of your health benefits plan. Review your health benefits plan documents for details on your coverage, or call your insurer with any questions by using the member services number on the back of your ID card.
     

I have a high deductible health plan. How can I manage my healthcare dollars?

Read our guide on High-Deductible Health Plans.
 

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Consumer Rights and Assistance

How can I learn more about what my health benefits plan covers and its cost-sharing features?  

Understanding your share of costs for out-of-network services will help you estimate your costs.
Learn more about your plan:

  • Read your plan documents
  • Ask your employerAsk your employer's human resources department about your coverage. 
  • Call, email or chat with your insurer: Most insurers have websites with online question forms. Some also offer live chats with customer service representatives. You may also call the member services phone number listed on the back of your insurance ID card.
     

How do I find out how my insurer sets out-of-network reimbursement?

Read your health benefits plan documents or contact your plan to find out. If you have insurance from your employer, ask a human resources (HR) representative.
 

I went to an in-network hospital, but I received a bill for out-of-network services. What can I do?

You may first choose to contact your insurer and discuss this with a member services representative, who may be able to help. Learn more from the FAIR Health guide on Appealing a Reimbursement Decision. If you are a consumer in New York, learn about extra protections you have by reading Protections for New York Consumers and see the section below on New York State’s Emergency Medical Services and Surprise Bills Law
 

What do I do if my health insurer denied or partially paid a claim that I submitted for out-of-network care?

You have the right to appeal your insurer’s decision. Read our guide on Appealing a Reimbursement Decision.
 

Where can I find help for appealing a reimbursement decision? 

Visit the Healthcare Resources section under Insurance Appeals and Assistance—you will find information on consumer assistance programs. Under “Healthcare Resources by State” you will find contact information for agencies that oversee insurance in each state. Also see our guide on Appealing a Reimbursement Decision
 

Where can I go to find more information about dental plans?

Learn more from the FAIR Health guide on Dental Plans.
 

Where can I learn more about flexible spending plans?

Learn more from the FAIR Health guide on Flexible Spending Plans.
 

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New York State's Emergency Medical Services and Surprise Bills Law

What is the "Emergency Medical Services and Surprise Bills" law?

This new law gives consumers in New York State the information they need to avoid unexpected healthcare costs and protect them from “surprise” bills for planned care and bills for emergency services from out-of-network doctors, hospitals and other facilities.

Under the law, insurers need to explain what out-of-network services they cover and how they decide what they will pay for out-of-network care, using the same standard so that you can easily compare different health benefits plans. The law also requires that consumers have access to more information about exactly which doctors, hospitals and facilities are in their health benefits plan’s network.

The law protects consumers if they have checked to make sure that all of their providers—including doctors, hospitals and any other facilities (like labs or imaging centers)—were in their health benefits plan’s network and later receive a “surprise bill” for services.

For more information, see Protections for New York Consumers: Understanding Your Out-of-Pocket Costs.

 

How can I find out if a doctor or hospital belongs to my health benefits plan's network?

Every year, your insurer should provide you with a list of all of the doctors and facilities in your network. In addition, your insurer must list all of its network doctors and facilities on its website. If providers or hospitals join or leave the network, the insurer must update the website within 15 days. Before you get care, you should double-check this information by contacting all of your healthcare providers and asking if they participate in the network that serves your specific health benefits plan.
 

What can I do if a provider claims to be “in-network” but actually is not?

You should let your insurer and your provider know that you asked about the provider’s network status before you got care and that the information you received was wrong. Since you tried to stay in your network, you should have to pay only the in-network cost, including your copay, coinsurance and deductible, if applicable. The provider and insurer will need to settle the rest of the bill with each other, or through New York’s dispute resolution program.
 

If I don’t have insurance, will the law help me with large bills?

If you are uninsured, the law provides some protection from bills for emergency services and for certain surprise bills from healthcare professionals, group practices, hospitals and diagnostic and treatment centers that have not made legally required disclosures on a timely basis. If an emergency or surprise bill seems too high, you may submit it for referral to the state’s dispute resolution program and an independent dispute resolution entity will decide on a reasonable price for you to pay. Note that the ACA requires that all individuals (with some exceptions) have health insurance or pay a penalty. If you don’t have insurance through your employer or a public program like Medicaid, you can take advantage of the New York State Health Insurance Exchange and choose a health benefits plan that suits your needs. Depending on your income level, you may be able to get a federal tax subsidy to help pay your premium.
 

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Licensing/Linking to this Website

I would like to link to your website from my organization’s website. How can I learn more?

FAIR Health welcomes organizations to link to our website and download materials for consumer use. FAIR Health incurs fees from third parties. For that reason, links to www.fairhealthconsumer.org for commercial purposes require a license agreement and payment of nominal fees. Such commercial purposes include, but are not limited to, links established by providers or third-party payors in connection with participation on state or federal health benefit exchanges.  

FAIR Health also licenses educational material, videos and cost lookup tools for use on organization websites and for other uses. Please contact info@fairhealth.org to learn more.
 

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Stay in Touch

How can I get FAIR Health updates?

Sign up for one or both of FAIR Health’s newsletters. Join FAIR Health on Facebook and Twitter. New features are also announced on the website homepage.
 

How can I give feedback on this website?

You can e-mail consumer@fairhealth.org, call 1-855-LOOKUP-1 (1-855-566-5871) or complete a survey


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