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

The New York state IDR framework lives or dies by 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 why it matters, and why it is the reason Claims Assassins files state IDR exclusively.

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 20% of billed charges are 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 as a presumptive benchmark for reasonable reimbursement. That is a statutory instruction, not a negotiation position.

The arbitrator begins the analysis with a number neither side can argue away. The insurer can argue that specific factors justify a downward adjustment. The provider can argue that clinical complexity justifies an upward adjustment. But the conversation starts at the 80th percentile, not at whatever the insurer’s proprietary database produced.

Compare to the Federal QPA

Federal IDR uses a different benchmark. The Qualifying Payment Amount. The QPA is calculated by the insurer from the insurer’s own claims data. It is not audited. It is not independently verified. It is self-reported by the party that has a direct financial interest in the number being as low as possible.

Providers have been fighting the QPA methodology in federal court since the No Surprises Act went into effect. The Fifth Circuit ruling in early 2025 acknowledged structural problems with the QPA-centric framework. The QPA remains a contested benchmark, and insurers continue to use it as the anchor number in federal proceedings.

Eliott Dear does not file federal IDR partly because of the enforcement gap, but also because the benchmark math is structurally rigged. When the benchmark itself is set by the insurer, the arbitration is a rigged coin flip with the provider holding the losing side.

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 optimization problem. Eliott Dear has been doing this for years. Filing a dispute in the wrong benchmark zone is a unforced error that a billing-department filing cannot avoid.

What This Means in Practice

The FAIR Health 80th percentile is the structural reason New York state IDR produces different outcomes than federal IDR. Combined with DFS enforcement, it converts the arbitration from a negotiation into a determination. The provider presents the FAIR Health number, the clinical complexity, and the attorney-signed submission. The arbitrator has a statute instructing them to start at the 80th percentile. The insurer has nothing to anchor a counter-argument except its own proprietary data, which is not the benchmark the statute directs the arbitrator to use.

That is how Eliott Dear wins 99% of filed state IDR disputes. The wins are structural. The process is built to produce them. The non-par provider just has to file the submission with the discipline of a legal document rather than the form-letter rhythm of a billing task.