Short answerThe QPA is, generally, a health plan's median contracted rate for the same or similar service, by the same type of provider, in the same geographic region, based on 2019 rates indexed for inflation. Plans often pay out-of-network claims at or near the QPA. In IDR it is one factor the arbiter considers, alongside other evidence.
Out-of-network physicians covered by the No Surprises Act often receive payments close to the plan's QPA. Many groups accept them because they assume that number is final. It isn't.
How the QPA is calculated
- the plan's own median contracted rate for the service
- for the same or similar specialty, in the same geographic region
- starting from 2019 contracted rates, indexed for inflation each year
Because it is the plan's own number, it can be lower than what an experienced group would negotiate.
Why the QPA may be low
- it reflects the plan's contracts, which may include low-paying networks
- it may not reflect case complexity or provider training
- calculation methods have been challenged in federal court, and parts of the rules have been revised
How the QPA is used in IDR
The certified IDR entity considers the QPA along with other information the parties submit, such as:
- the provider's level of training and experience
- patient acuity and case complexity
- market share of the parties
- good-faith efforts to contract and prior contracted rates
What to do with a QPA-level payment
- confirm the plan is subject to the No Surprises Act
- start open negotiation within 30 business days
- if negotiation fails, file IDR within 4 business days after it ends
Related: the 30-business-day clock and No Surprises Act / IDR service.
This article is general billing information, not legal or coding-compliance advice. Payer rules, CPT descriptors and federal guidance change; check the current versions for your claims.