A recent study commissioned by the Americans for Fair Health Care (AFHC), evaluating the Qualifying Payment Amounts (QPAs) under the No Surprises Act (NSA) Independent Dispute Resolution (IDR) process, finds that reported QPAs do not align with the actual median in-network contracted rates.
The results of the study have significant implications for healthcare providers. Because QPAs are used to guide IDR outcomes and determine patient cost-sharing, inaccurate or artificially low QPAs may:
- Lead to underpayment for out-of-network services
- Anchor payer offers below market value
- Undermine the policy goals of the NSA—protecting patients while ensuring fair provider reimbursement
Key Takeaways
The study compared CMS IDR QPA data to insurer published contracted median in-network rates and found:
- In 60.6% of the IDR disputes evaluated, the median in-network contracted rate was higher than the QPA.
- Among those cases, the median in-network contracted rate, on average, was 290.5% higher than the QPA.
Why the NSA QPA Accuracy Matters
Under the NSA, QPAs are defined as the median in-network contracted rate for the same or similar service in the same MSA. QPAs serve two primary purposes:
- Calculating the patient cost sharing amounts – ensuring that patients pay no more than the in-network amount for covered services
- Supporting IDR arbitration – as one factor among several in determining fair reimbursement for out-of-network services.
Impact of Understated QPAs:
- Patient cost sharing calculations can be incorrect
- Initial payor offers to providers are anchored below actual median rates
- NSA effectiveness of protecting patients and ensuring fair payment is compromised
QPA Oversight is Lacking
Despite statutory obligations to audit QPA calculations, there has been limited oversight:
As of 2025:
- CMS reported initiating 25 QPA Audits
- Only one audit report has been publicly released
Without routine audits, transparency, or meaningful consequences, there is little incentive for insurers to provide methodological accuracy. Research also suggests, “insurers may be incentivized to report inaccurate and below market QPAs, not only because of the rhetorical value it creates, but because it enables increased profit opportunity through shared savings arrangements” with third party administrators.
QPA Under Scrutiny from the Start
Concerns regarding the QPA have been raised since before the implementation of the NSA . Litigation brought by the Texas Medical Association (TMA) illustrates the ongoing disputes over QPA application and methodology:
- TMA I – Challenged rules requiring arbitrators to presume the QPA was the correct payment amount. The court ruled this conflicted with the statute and vacated the rule.
- TMA II – Challenged updated rules that treated the QPA as the primary factor to be considered in IDR decisions. The court confirmed that arbitrators must treat the QPA as one factor among several statutory factors, not as the final or controlling payment amount.
- TMA III – Directly challenged the methodology for calculating the QPAs, citing practices such as “ghost rates”, defined as historical contracted rates for services that a provider never actually performs or bills, and the use of contracted rates for services outside the provider’s specialty under the same plan. Both practices, TMA argued, artificially skew the QPA lower.
While these cases addressed statutory interpretation, procedural application, and calculation methodology, the new study provides data-driven validation, showing that reported QPAs often do not reflect actual median in-network contracted rates.
Conclusion
To protect the integrity of the NSA, governmental enforcement and oversight are critical. Since QPAs are currently calculated by insurers with little transparency or oversight, regular audits and public reporting are needed. CMS should ensure that QPA calculation methods fully align with the statute. Congress explicitly assigned oversight responsibilities to the Departments, and honoring those responsibilities is essential to maintaining the NSA’s promise of fair reimbursement and patient protection.
To avoid disruption, Federal Regulators have temporarily decided insurers may continue to use the original QPA 2021 methodology until at least February 1, 2026 with a possible further extension to August 2026.
Contact a Managed IDR Specialist from Allia Group Now
For providers impacted by low QPAs and looking to strengthen their IDR strategy, external support may help improve outcomes and reduce administrative burden.
Allia Group’s managed IDR service takes the workload off of healthcare providers through the full IDR lifecycle—from dispute initiation to resolution. Our data-driven approach supported by our team’s legal expertise helps ensure claims are evaluated appropriately and in accordance with the statute for maximum recovery potential.
Contact us now for a complementary consultation.
