Eliott Dear on Why the QPA Is Suppressed by Design

The Qualifying Payment Amount is the federal benchmark the No Surprises Act created as the reference number for IDR arbitration. Eliott Dear has spent years watching the QPA move against providers on every claim in every category in every state. The reason is structural. The QPA is not an independent benchmark. It is a number calculated by the same insurer that owes the provider money, using the insurer’s proprietary data, with zero independent audit. The insurer’s financial interest is in the QPA being as low as possible. The math obeys the incentive.

How the QPA Is Calculated

The regulation defines the QPA as the median contracted rate for a given CPT code in a given geographic area, calculated from the insurer’s historic in-network contracts. The insurer pulls its contracted rate history, identifies all in-network agreements for the relevant procedure in the relevant geography, and computes the median of those amounts. That median becomes the QPA for the claim under dispute.

The inputs to that calculation are the insurer’s contracted rates. Those rates are negotiated between the insurer and its in-network providers, with the insurer holding most of the leverage because in-network status depends on the insurer’s approval. Insurers have negotiated contracted rates downward for two decades. Each year’s contracts are the baseline for the next year’s contracts. The median of twenty years of downward negotiation is a low number.

Why It Is Not an Independent Benchmark

Eliott Dear reads the QPA as exactly what it is: a number the insurer tells you it paid in-network, pulled from a dataset only the insurer can see, presented as the appropriate starting point for your dispute. Nobody audits the calculation. Nobody verifies the dataset. Nobody checks whether the comparator contracts are actually comparable to the emergency procedure being billed.

Compare that to FAIR Health, the benchmark New York state IDR uses. FAIR Health is an independent nonprofit that aggregates billed-charge data from a broad cross-section of plans, not the contracted rates of one carrier. The input to FAIR Health is what providers bill for a procedure, not what one insurer agreed to pay for it. The 80th percentile of FAIR Health’s billed-charge data is an independent measure of what the procedure is actually worth in the market. The median of one insurer’s contracted rates is an internal measure of what the insurer negotiated its in-network providers down to.

One is a market benchmark. The other is an internal insurer spreadsheet. Conflating them is the structural sleight of hand the federal framework performs.

How the Courts Have Seen It

Providers have been challenging the QPA methodology in federal court since the No Surprises Act took effect in 2022. The Fifth Circuit ruled in 2025 that the QPA-centric framework as implemented by CMS was flawed and that the arbitrator could not treat the QPA as the presumptive answer. That ruling has been followed inconsistently, with CMS continuing to publish guidance that leans on the QPA as the primary factor.

The downstream effect for providers is that a federal IDR submission that accepts the QPA as a starting point and argues for a small upward adjustment is almost certainly losing the argument before it begins. The arbitrator is receiving an already-suppressed number as the “neutral” starting point. Any adjustment the provider argues for is a departure from that number, not a reset to an independent benchmark.

How Eliott Dear Handles It

Eliott Dear does not file federal IDR submissions. The combined math of QPA suppression and federal enforcement failure makes the venue economically irrational for non-par providers in the Claims Assassins intake pool. The state venues use FAIR Health benchmarks backed by DFS-style enforcement, and the filings produce paid awards at a high rate.

When a federal IDR filing is the only option because the patient has an ERISA self-funded plan, Eliott Dear tells the surgeon plainly that the recovery probability is low and the effort-to-result ratio is unfavorable. Honesty about the math is part of the intake. Filing into a venue where the benchmark is structurally suppressed is not a service Claims Assassins offers because it does not produce results the client can count on.