Federal IDR guides
What is the QPA, and how is it calculated?
The qualifying payment amount is the payer's own benchmark. How it is built, what the payer must disclose, and what the August 2026 court ruling changes.
Verified September 11, 2026
Short answer
The QPA is the payer's typical in-network rate for the same service in the same area, frozen at January 2019 and bumped up for inflation each year. The payer works it out. It sets what the patient pays and it is where IDR starts. It is not where IDR ends.
In 2025, the median winning offer in federal IDR was 399% of the QPA.
Median winning offer
399%
Of QPA, 2025
Provider win rate
86.4%
Decided lines, 2025
Rate snapshot date
Jan 2019
Trended for inflation since
Weight in IDR
One of six
Factors, with no presumption
How the payer builds it
Take every in-network rate the plan had for that service, from that kind of provider, in that area, on January 31, 2019. Find the middle one. Add inflation for each year since.
Fewer than three contracted rates? The plan uses an outside database. It counts rates, not contracts, so one contract covering several providers at separately negotiated rates can supply more than one. New billing code? It uses the closest old one.
The area is usually the state or a metro. The plan also splits by market: individual, small group, or large group. So one plan can have several QPAs for one service.
What the payer has to tell you
Two lists. One arrives on its own. The other you have to ask for.
With every initial payment or denial on a No Surprises Act claim:
| Item | What it means |
|---|---|
| The QPA for each service | The number itself |
| A certification | The payer says the QPA was worked out under the rules |
| A statement about your rights | That you can open negotiation, and file for IDR if it fails |
| Contact information | A person or office, with a phone number and an email |
On request, the payer must then give you, in good time:
| Item | What it means |
|---|---|
| Whether it used a database | Because it had too few contracted rates |
| Whether it used a related code | Because your code is new |
| Whether any rates come from contracts not paid per service | Capitated or bundled |
A missing or thin disclosure is the payer's failure. It does not stop you filing. Ask for it in writing. Asking does not pause anything: the 30 business days to open negotiation is a separate clock and it keeps running.
How much weight the QPA gets in IDR
The IDR entity has to look at the QPA. It also has to look at anything either side sends in about:
- The provider's training, experience, and quality
- The provider's or payer's market share in the region
- How sick or complex the patient was
- Whether the provider is a teaching facility, and its case mix
- Both sides' good-faith efforts to reach a contract
- Any contracted rates between the two parties in the last four years
The QPA is not assumed to be right. Two federal courts threw that idea out in 2022 and 2023. The entity picks whichever offer it finds more reasonable, looking at all of the above.
What the IDR entity may not consider: the provider's billed charges, usual and customary charges, or Medicare, Medicaid, or other government rates.
What is changing
The QPA is changing
On August 11, 2026 a federal appeals court said two parts of the QPA method break the law:
- Ghost rates are out. Contract rates for services a provider never performs can no longer be counted. They were dragging the median down.
- Bonus and incentive pay is in. Rates must reflect the full amount a contract can pay.
Both changes push the QPA up. CMS has said guidance is coming and that IDR carries on as before. Its existing relief is not open-ended: it covers services furnished before October 1, 2026, and payers using it have to disclose that they are. For services on or after that date, check for newer guidance before you assume the old method still applies.
What to do with it
Get the QPA disclosure, check it, and keep it. If it never arrives, write that down and keep going. The payer's failure to disclose does not bar you from IDR, and you can ask CMS for more time. What you cannot do is let the negotiation deadline pass while you wait.
Treat the QPA as the payer's opening bid. In 2025, IDR entities picked the provider's offer 86% of the time, at a typical four times the QPA.
Do not build your offer off the QPA. Build it off what the service is worth and what you can prove.
Sources
45 CFR 149.140 (QPA calculation and disclosure); 45 CFR 149.510(c) (IDR entity considerations); CMS FAQs About Affordable Care Act and Consolidated Appropriations Act, 2021 Implementation Part 73 (April 2026), QPA enforcement relief through October 1, 2026; Texas Medical Association v. HHS, No. 23-40605 (5th Cir., en banc, Aug. 11, 2026); CMS No Surprises Act notice, August 13, 2026; CMS Federal IDR Public Use Files, 2025.
Every number on this page comes from public CMS files or the federal rule. Our methodology explains how we count. Questions? sales@recoursehealth.com
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