Eliott Dear on the FAIR Health 80th Percentile: Why It Anchors New York State IDR

The New York state IDR framework is built around one number. The FAIR Health 80th percentile. Eliott Dear has spent more time staring at FAIR Health benchmark data for CPT codes in the New York metro area than at any other dataset in his career. Here is what that number is, and how a New York submission is built around it.

Who Is FAIR Health

FAIR Health is an independent nonprofit that aggregates billed-charge data from a large cross-section of commercial health plans. Its dataset reflects the actual charges providers submit for a given procedure, in a given ZIP code, using a given CPT code. The 80th percentile of that dataset answers a specific question: what amount represents the charge level at which only one in five billed charges is higher?

That is not the insurer’s opinion of reasonable. That is not the provider’s opinion of reasonable. It is a statistical fact derived from a broad industry dataset that neither side controls.

What New York State IDR Does With It

When a non-par provider files a New York state IDR dispute for an emergency or surprise service, the arbitrator is instructed to consider the FAIR Health 80th percentile, the benchmark named in New York law. That is a statutory instruction, not a negotiation position.

Neither side picks that number. The insurer can argue that specific factors justify a downward adjustment. The provider can argue that clinical complexity justifies an upward adjustment. Both arguments are made against the same independent benchmark.

Sorting the Claim First

The benchmark only matters once the claim is in the right forum. Eliott Dear sends every fully insured claim to New York state IDR, where the FAIR Health 80th percentile is the benchmark the law names.

That is why plan classification sits in every package alongside the FAIR Health number and the clinical complexity. The plan is sorted before the benchmark is pulled.

Geography Matters

FAIR Health data is geographically specific. The 80th percentile for CPT 13152 in ZIP 11208 (Brooklyn) is dramatically different from the 80th percentile for the same code in ZIP 11418 (Queens), which is different again from the 80th percentile for the same code in ZIP 11355 (Flushing). The variance can be multiples of the lower number.

A properly built state IDR submission treats facility geography, CPT code, and operative documentation as three dimensions of the same problem. Eliott Dear has been doing this for years. Filing a dispute in the wrong benchmark zone is an unforced error, and checking the zone is part of building the package.

What This Means in Practice

The FAIR Health 80th percentile is the fixed point of the New York framework. The provider presents the FAIR Health number, the clinical complexity, and the attorney-signed submission. The arbitrator has a statute naming the benchmark. Every argument in the dispute is made against that number.

That is the structure Eliott Dear files into. Every state IDR submission goes out as a full documented package (the FAIR Health number, the clinical complexity, the plan classification) signed under his own bar number. The work is filing the submission with the discipline of a legal document rather than the form-letter rhythm of a billing task.