Qualifying payment amount (QPA)
The qualifying payment amount (QPA) is the benchmark figure the No Surprises Act turns on. Under 45 CFR 149.140 it is generally a health plan's or issuer's median contracted rate for the same or similar item or service in the geographic region, calculated from a base date and trended forward by the Consumer Price Index. It does two jobs: it is generally the basis for the patient's in-network cost-sharing in a protected surprise-billing situation, and it is one of the factors a certified IDR entity weighs when it resolves an out-of-network payment dispute.
Updated
The qualifying payment amount (QPA) is the amount a health plan or issuer calculates under the No Surprises Act as the reference rate for an out-of-network item or service. Under 45 CFR 149.140, it is generally the plan's or issuer's median contracted rate — the middle rate among what it has agreed to pay in-network providers for the same or similar item or service in the same geographic region — determined as of a base date and adjusted forward for inflation.
For items and services furnished in 2022, the methodology takes the median contracted rate as of January 31, 2019 and increases it by the change in the Consumer Price Index for All Urban Consumers (CPI-U) (45 CFR 149.140(c)(1)(i)). The plan performs the calculation, and the QPA is expressed as a single dollar figure for the item or service.
In practice
The QPA does two distinct jobs under the law. First, in a situation the No Surprises Act protects — emergency services, or non-emergency services from an out-of-network provider at an in-network facility — the patient's cost-sharing is generally calculated from the QPA rather than from the out-of-network provider's charge, which is how the patient is kept whole (45 CFR 149.110, 149.120). Second, when the provider and the plan cannot agree on the total out-of-network payment and take the dispute to the federal Independent Dispute Resolution process, the QPA is one of the factors the certified IDR entity must consider (45 CFR 149.510(c)(4)(iii)).
A provider that questions a payer's QPA cannot see the underlying contracted rates that produced it, so the number itself is difficult to audit from the outside. The QPA is a plan-calculated figure, not a market average and not the provider's billed charge; the IDR process is where its weight is tested against the other permitted factors.
Commonly confused with
- Allowed amount: The allowed amount is the total a plan recognizes as payable for a service under a particular patient's benefits, from which cost-sharing and plan payment are drawn. The QPA is a specific No Surprises Act construct — a median-contracted-rate benchmark used to set protected cost-sharing and to inform an IDR determination — not the plan's allowed amount on an ordinary in-network claim.
- Billed charges: Billed charges are what the provider lists for a service. The QPA is deliberately independent of billed charges; in fact a certified IDR entity is prohibited from considering billed charges or usual and customary charges when it weighs the QPA against the other factors (45 CFR 149.510(c)(4)(v)).