What is the qualifying payment amount (QPA)?
Verdict Consulting Group Research · Updated
Answer
The qualifying payment amount (QPA) is a plan's median contracted rate for the same or a similar service, by provider specialty and geographic region, as of January 31, 2019, adjusted each year for inflation. Certified IDR entities must consider it in every payment determination. In August 2026 the en banc Fifth Circuit held that non-negotiated ghost rates cannot be counted.
Detail
How the statute defines it
| Element | Statutory text (42 U.S.C. 300gg-111(a)(3)(E)) |
|---|---|
| Base | Median of the contracted rates the plan or issuer recognized as the total maximum payment |
| Comparison | Same or similar item or service, provider in the same or similar specialty |
| Geography | Geographic region where the item or service is furnished |
| Base date | January 31, 2019 |
| Updates | Increased annually by the CPI-U |
Under 300gg-111(c)(5)(C), a certified IDR entity must consider the QPA together with any additional circumstances the parties submit, such as provider training and market share.
What the en banc Fifth Circuit decided
On August 11, 2026, in Texas Medical Association v. HHS, the en banc court held that the July 2021 interim final rule unlawfully required insurers to include non-negotiated "ghost rates" and to exclude bonus and incentive payments from the QPA. It upheld the exclusion of single-case agreements. The court affirmed the district court's judgment in part, reversed in part and remanded.
Read the analysis
Sources
- Legal Information Institute, Cornell Law School — 42 U.S. Code § 300gg-111 — Preventing surprise medical bills ()
- U.S. Court of Appeals for the Fifth Circuit — Texas Medical Association v. HHS, No. 23-40605 (5th Cir. Aug. 11, 2026) (en banc) ()
General information only, not legal advice. Verdict Consulting Group is not a law firm.