No Surprises Act: Six FAQs about the qualifying payment amount (QPA)

worried couple checking bills living room

Now that the No Surprises Act (NSA) is in full swing as of January 1, 2022, physicians are grappling with many questions, one of which is: Should I go in-network with certain payers or stay out-of-network?

Going in-network (i.e., contracting directly with a payer) means physicians may not need to worry about patient notification requirements under the NSA. However, remaining out-of-network means they may run the risk of forgetting to notify patients of their out-of-network status, subsequently forgoing their right to balance bill. Instead, they must accept the qualifying payment amount (QPA) as outlined in Part 1 of the NSA.

Here are six frequently asked questions (FAQ) about the QPA along with two questions physicians should consider as they operationalize the NSA.

Q: What exactly is the QPA?

A: Generally speaking, the QPA is the payer’s median contracted amount. The QPA is used to determine individual cost sharing for items and services covered by the balance-billing protections in the NSA.

What’s interesting is that in some cases, the QPA may be higher than the physician’s contracted rate with the payer. In others, it may be lower. For example, many small medical practices that have not been able to negotiate higher contracted rates have chosen to remain out-of-network. However, the QPA under the NSA takes into consideration the contracted rates obtained by larger practices with greater leveraging power. Thus, the QPA for smaller practices may be higher than any rate those practices could have negotiated with payers directly.

Q: How is the QPA calculated?

A: The QPA is the median of all contracted rates of all plans for the same or similar item or service rendered by a provider in the same or similar specialty in the same geographic region.

Q: What if the amount the physician bills is less than the QPA?

A: Then the cost-sharing amount is based on the lesser of the two (i.e., the amount billed by the provider for the item or service).

Q: What if the payment for an item or service is not on a fully fee-for-service basis (e.g., (e.g., under bundled and fully or partially capitated arrangements)?

A: QPA methodology establishes an approach for calculating a median contracted rate in these cases. See this CMS presentation (slide 16) for more information.

Q: What about unit-based services?

A: Special rules apply for anesthesia services as well as air ambulance services. See this CMS presentation (slides 17-20) for more information.

Q: What if it’s a new service code? How is the QPA determined?

A: A new service code is defined as one that was created or substantially revised in a year after 2019. See slides 30 and 31 for more information about how related service codes are used to determine the QPA for new service codes.

Two questions to consider:

  1. What are the QPAs for my most frequently billed items or services if I don’t notify patients of my out-of-network status? The July 2021 interim final rule requires payers to disclose the QPA for each initial payment or notice of denial of payment.
  2. How does that payment compare with a directly contracted rate? Does it make sense to go in-network with any payers, or is it more financially advantageous to accept the QPA?

Have questions about the QPR and how it might affect your practice or organization? Contact us at Rivet Health Law.