Eliott Dear on Why the Benchmark Has to Be Independent

FAIR Health is the benchmark New York state IDR uses. Eliott Dear has spent years building submissions around it. The reason is structural. FAIR Health is an independent benchmark. It is not a number calculated by the same insurer that owes the provider money, using the insurer’s proprietary data, with zero independent audit. That difference is the whole argument.

How FAIR Health Is Built

FAIR Health is an independent nonprofit that aggregates billed-charge data from a broad cross-section of plans, not the contracted rates of one carrier. The input to FAIR Health is what providers bill for a procedure, not what one insurer agreed to pay for it.

The 80th percentile of FAIR Health’s billed-charge data is an independent measure of what the procedure is actually worth in the market.

What an Insurer’s Own Number Is

An insurer’s own number is built from its contracted rates. Those rates are negotiated between the insurer and its in-network providers, with the insurer holding most of the leverage because in-network status depends on the insurer’s approval. Insurers have negotiated contracted rates downward for two decades. Each year’s contracts are the baseline for the next year’s contracts. Twenty years of downward negotiation produces a low number.

Eliott Dear reads that number as exactly what it is: a figure the insurer says reflects its in-network contracts, pulled from a dataset only the insurer can see, presented as the appropriate starting point for your dispute. Nobody audits the calculation. Nobody verifies the dataset. Nobody checks whether the comparator contracts are actually comparable to the procedure being billed.

One is a market benchmark. The other is an internal insurer spreadsheet. Treating them as the same thing is the sleight of hand every submission has to correct.

Why the Starting Point Matters

An arbitrator reads what is in front of them. If the first number in the record is the insurer’s, everything after it is measured against that number.

A submission that accepts the insurer’s own number as its starting point and argues for a small upward adjustment is arguing on the insurer’s terms. Any adjustment the provider argues for is a departure from that number, not a reset to an independent benchmark.

How Eliott Dear Handles It

Eliott Dear leads every state IDR submission with FAIR Health. The state venues use FAIR Health benchmarks, and the submission puts that benchmark first: the 80th percentile for the procedure and the geography, then the facts of the case.

Intake starts with the EOB. Eliott Dear reads it, sorts the plan, and tells the surgeon plainly which claims belong in state IDR. Honesty about the math is part of the intake.