What is the qualifying payment amount (QPA) under the No Surprises Act?

The QPA is the plan's median contracted rate for the same or similar service, furnished by a provider in the same or similar specialty, in the same geographic region and insurance market, anchored to rates as of January 31, 2019 and increased each year by the consumer price index (CPI-U). The plan calculates it, it sets the patient's cost sharing on protected claims, and it is the reference point arbiters must consider in federal IDR.

Is the QPA what the plan has to pay an out-of-network provider?

No. The QPA is a benchmark, not a payment standard. Plans often make their initial payment at or near the QPA, but the No Surprises Act resolves what is actually owed through open negotiation and, failing that, IDR. In decided federal disputes from 2023 through 2025, the median award was about 4.7 times the QPA, which is the clearest public evidence that initial payments and final values are very different numbers.

Why is the QPA controversial?

Because the plan calculates its own benchmark. Providers and courts have scrutinized how plans build QPAs, including which contracts count toward the median, and pieces of the calculation methodology have been litigated and revised more than once. For a filing provider the practical takeaway is that the QPA is the starting anchor, not the ceiling, and the public record shows arbiters regularly award well above it.

Answers / What is the QPA

What is the QPA (qualifying payment amount)?

The qualifying payment amount is the health plan's median contracted rate for the same or similar service, by a provider in the same or similar specialty, in the same geographic region and insurance market, anchored to January 31, 2019 and increased each year by the consumer price index (CPI-U). The plan calculates it. It sets the patient's cost sharing on No Surprises Act claims and is the reference point in federal IDR. It is not what the service is worth: in decided disputes from 2023 through 2025, the median arbitration award was about 4.7 times the QPA.

Every number in a federal IDR dispute is expressed relative to the QPA. The plan's initial payment usually sits at or near it. Both parties' offers are evaluated against it. The public use files report outcomes as multiples of it. If you file disputes, or are deciding whether to, you need to know three things about the QPA: where it comes from, what it does, and what it does not do.

Where it comes from

The QPA is a median, not an average, of the plan's own contracted rates for that service code, provider specialty, region, and market segment, frozen as of January 31, 2019 and walked forward by CPI-U inflation each year. Two things follow from that construction. First, it reflects 2019 network economics plus general inflation, not what the plan pays anyone today, and medical rate growth has not tracked CPI-U. Second, each plan computes its own QPA from its own contracts under methodology rules that have been litigated and revised more than once, including questions about which contracts count toward the median. Providers cannot recalculate it from the outside, though they can and do challenge implausible ones.

What it does

Two jobs. For patients, it sets cost sharing on protected claims: the patient pays as if the care were in-network, with the QPA standing in for the in-network rate. For disputes, it is the benchmark the arbiter must consider alongside other permitted factors such as the provider's training and experience, case acuity, and prior contracting history. Federal IDR is baseball-style: each side submits one number, and the arbiter picks one. Those numbers are argued, and reported, as multiples of the QPA.

What it does not do

The QPA does not cap the award, and it is not a payment standard. This is the single most expensive misunderstanding in out-of-network revenue. A plan that pays 100 percent of QPA has not necessarily paid what the claim resolves for, it has paid the opening anchor. The CMS public use files make the gap concrete: across 3.39 million disputes from 2023 through 2025, providers prevailed 85.8 percent of the time and the median winning outcome was about 4.7 times the QPA. Groups that accept initial payments at QPA as final, on claim types their peers routinely arbitrate, are accepting roughly a fifth of the median arbitrated value. The per-payer and per-specialty breakdowns are at idrexplorer.com.

None of this means every claim should be filed. It means the QPA on a remittance is the beginning of a pricing conversation that the deadline clock is already timing. The cost of having that conversation is now modest, and the public record tells you in advance how it tends to end for your specialty and your payers.

What is your specialty's multiple?

The free NSA audit benchmarks your state, specialty, and payers against every published decision. Or get a flat fee quote to start filing.