One of the major issues that New Jersey medical patients have been experiencing in the last 20 years is the lack of transparency with regard to medical billing. The federal government attempted to alleviate that problem in 2022 with the passage of the No Surprises Act (NSA).
The Qualifying Payment Amount (QPA) is a key element of the NSA. This legislation, which took effect in January 2022, protects consumers from unexpected surprise medical bills arising from out-of-network care in emergency or non-emergency settings. The QPA is the standard used to determine how much a medical consumer should pay for services covered under the NSA. Unfortunately, the QPA has sometimes resulted in healthcare providers being denied fair payment for their services.
If your medical practice was underpaid, delayed, or denied reimbursement for medical services, your claim may fall under commercial insurance. Contact Kotlar Cohen to dispute your QPA — speak to an attorney. We have been helping healthcare providers navigate unfair insurance QPAs and IDR arbitration since the NSA was enacted.
Healthcare providers win approximately 86% of IDR disputes, and courts have repeatedly sided with them when an appeal has been litigated. Because of strict statutory guidelines, you must act urgently in order to preserve all your legal rights. Contacting Kotlar Cohen as early as possible in the process ensures that you will be in a position to get the best possible outcome.
What is the Qualifying Payment Amount (QPA)?
Under the NSA, the QPA is equal to the median of the contracted rates a health plan has with in-network providers for the same or a similar item or service. This median rate is calculated for services provided in a specific geographic region and insurance market as specified in the NSA. The QPA’s primary purpose is to establish a recognized amount upon which a patient’s out-of-pocket costs must be based when they receive a bill from an out-of-network provider.
The QPA applies specifically to certain services furnished by an out-of-network provider at an in-network facility. The QPA acts as the baseline payment standard for the payer-provider dispute process, unless there is a state-specific law or other regulation that establishes the amount of the charges. The QPA establishes a fair market value for a service without relying on billed charges.
How is the QPA calculated?
The calculation of the QPA is a process that insurance companies must engage in when they are using their own proprietary claims data. The amount is the median of contracted rates as of a specific historical date: January 31, 2019.
Insurance companies are required under the NSA to aggregate all contracted rates for the identical service code across all their plans in the same insurance market. This aggregation includes all individual, small group, and large group market plans. The resulting median is then adjusted annually for inflation.
The QPA calculation must be performed using contracted rates specific to the geographic region where the service was furnished; the standard geographic region is defined by Metropolitan Statistical Areas. If an insurance company lacks sufficient data for that geographic region, it must follow an alternative methodology.
Why the QPA is Often Too Low
In many cases, QPAs are below fair market value, and several factors explain why.
Use of lower‑tier rates – When a procedure is billed with an assistant’s rate, reimbursement is typically a fraction of the primary doctor’s rate.
Ineligible or out‑of‑scope claims – About 39% of disputes in 2024 were found to be out‑of‑scope, meaning that the bill wasn’t covered by the NSA, and therefore, the QPA methodology wasn’t required
Market‑level median calculation – The QPA is the median of all rates in the region, not the highest or average. Accordingly, if there is a concentration of providers that are paid at the lower end of the scale, the median will be pulled down.
Limited oversight and potential underreporting – A 2026 study found that in the majority of disputes regarding QPA, the median in‑network rate was higher than the QPA, with the difference averaging 290%. Despite statutory audit requirements, the Centers for Medicare & Medicaid Services has initiated only 25 QPA audits since 2025, and only one report has been released. Without routine audits, there’s little incentive for insurers to abide by the NSA faithfully.
Legal and procedural changes – NSA rules required arbitrators to treat the QPA as the correct payment amount, but courts ruled that this rule was not supported by the NSA. Now, the QPA is just one factor among many in arbitration decisions.
Provider perception vs. market reality – Healthcare providers often see QPAs as “too low” because they are paid more in‑network than out‑of‑network. But under the NSA, out‑of‑network payments are capped at the in‑network rate to protect patients. If plans routinely paid more out‑of‑network, providers would leave networks – so the QPA reflects a market equilibrium
What the Law Says About QPA Arbitrations NSA
Independent Dispute Resolution (IDR) arbitration is a federal process under the NSA that resolves payment disputes between out-of-network healthcare providers and health plans through binding, “baseball-style” arbitration. A Kotlar Cohen attorney will know how the IDR process works.
The QPA is used in the IDR process for:
- Emergency services at out-of-network facilities
- Non‑emergency services by out-of-network providers at in‑network facilities
- Air ambulance services
The requirements for the QPA and its use in IDR are set forth in the NSA and implemented by the Departments of Health and Human Services, the Labor Department, and the U.S. Treasury. The process is designed to prevent balance billing and ensure consistent, fair payment standards across the country.
Unfortunately, this is not always the case, and compliance is not always straightforward. In federal IDR arbitration, the QPA is not just a calculation – it is a statutory payment standard that arbitrators must apply to resolve out-of-network service disputes, ensuring that both patients and providers are protected from excessive or unfair billing. However, the process is not always smooth and transparent, as it should be, and mistakes are often made.
How to Challenge the QPA with Credible Information
Independent Dispute Resolution (IDR) arbitration is a federal process under the NSA that resolves payment disputes between out-of-network healthcare providers and health plans through binding, “baseball-style” arbitration. A Kotlar Cohen attorney will know how the IDR process works.
The QPA is used in the IDR process for:
- Emergency services at out-of-network facilities
- Non‑emergency services by out-of-network providers at in‑network facilities
- Air ambulance services
The requirements for the QPA and its use in IDR are set forth in the NSA and implemented by the Departments of Health and Human Services, the Labor Department, and the U.S. Treasury. The process is designed to prevent balance billing and ensure consistent, fair payment standards across the country.
Unfortunately, this is not always the case, and compliance is not always straightforward. In federal IDR arbitration, the QPA is not just a calculation – it is a statutory payment standard that arbitrators must apply to resolve out-of-network service disputes, ensuring that both patients and providers are protected from excessive or unfair billing. However, the process is not always smooth and transparent, as it should be, and mistakes are often made.
How to Challenge the QPA with Credible Information
If you believe the QPA used to determine your out-of-network cost-sharing under the NSA is incorrect or inappropriate, you can challenge it by providing credible, documented evidence that supports your position.
To challenge the QPA, you must show that:
- The median rate used is not representative of actual market rates.
- There are significant outliers or higher rates in the dataset that should be included.
- The inflation adjustment applied is incorrect or inconsistent with the NSA.
- Your provider’s actual negotiated rates or market benchmarks are substantially higher than the QPA.
It is typically an uphill battle to dispute the QPA. You need demonstrable facts and evidence that the standard used was incorrect. Kotlar Cohen NSA arbitration attorneys have extensive experience in this area and will guide you in your dispute. If you lose at the IDR level, you can file a lawsuit, but this is rarely done, and due to the deference that the federal courts apply to the IDR process, not often successful.
FAQs
Q - What is the Qualifying Payment Amount QPA?
A – The QPA is defined as the median of the rates a health plan has with in-network providers for the same or a similar item or service. This median rate is calculated for services provided in a specific geographic region and insurance market.
Q - How QPA is calculated?
A – The calculation of the QPA is a process that insurance companies must execute using their own proprietary claims data. The amount is the median of rates as of a specific historical date: January 31, 2019. This date establishes a fixed historical reference point for the rate base.
Q - Can I dispute the QPA?
A – If you believe the QPA is incorrect or that your payment should be based on a different amount, you can dispute it through the federal IDR process. If you are unsatisfied with the IDR decision, you can appeal to the federal court under the NSA’s dispute resolution provisions. This is a last‑resort step and requires filing within the statutory timeframes.
Q - What is “credible information” in IDR arbitration?
A – Credible information includes:
- Published market rate studies or industry reports
- Healthcare contracts showing higher rates for the same service.
- Peer-reviewed medical economics research on regional payment rates.
- State or federal rate schedules for the same specialty and facility type.
Q - Does the QPA determine how much I get paid?
A – The QPA does not directly set your total payment from a health plan, but it is a key benchmark that can influence how much you pay out of pocket and how much a provider or payer will pay you.
Call Kotlar Cohen Today With Your QPA Issues
Kotlar Cohen has been at the forefront of QPA litigation since the NSA was passed in 2022. We work tirelessly for our medical provider clients to ensure you are fairly paid for the services which you provide. Contact Kotlar Cohen today to represent you with any QPA issues.