Knowledge Center

Effective January 1, 2022, the federal No Surprises Act (enacted as part of H.R. 133, the Omnibus Appropriations and Emergency Coronavirus Relief Act) protects patients from surprise medical bills when they receive out-of-network emergency care, or non-emergency care from an out-of-network provider at an in-network facility, unless the proper notice and consent steps have been followed.

Under the Act, out-of-network care must be treated by the plan as though it were in-network: patients cannot be billed beyond their in-network cost-sharing obligations.

The law sets out a structured process for resolving payment disputes between payors and out-of-network providers. If you disagree with the payment amount offered by a plan, you have the right to open negotiations, and, if necessary, move to a binding independent dispute resolution (IDR) process. One of the required factors that an arbitrator must consider is the “Qualifying Payment Amount.”

What Is a Qualifying Payment Amount (QPA)?

The QPA is typically defined as the median of contracted in-network rates for the same service, within the same geographic region and insurance market, as of January 31, 2019. That figure is adjusted upward using the Consumer Price Index for All Urban Consumers (CPI-U).

Health plans and payors are subject to auditing and regulatory complaint protocols with respect to the accuracy of their QPA calculations.

Why the QPA Matters for Out-of-Network Surgeons

The QPA serves as the benchmark starting point in determining how much the out-of-network provider may receive for a covered service. It also forms the basis for how much a patient must pay in cost-sharing.

Once negotiations between provider and payor begin, if no agreement is reached, the provider can initiate arbitration under the IDR process and the arbitration outcome will be publicly reported as a percentage relative to the QPA.

CHRMS: Empowering Independent Surgeons in the New Reimbursement Landscape

For independent and out-of-network surgeons, the QPA and the payment-dispute framework under the No Surprises Act add strategic complexity to reimbursement. At CHRMS, we help you understand how the QPA applies to each claim, monitor the payor’s QPA calculations for accuracy, and support negotiation or arbitration when appropriate.

Our aim: to ensure you are equipped to advance your reimbursement rights so you can focus on surgical care, while we focus on protecting your revenue.