Fifth Circuit Vacates No Surprises Act Qualifying Payment Amount, a Major Win for Providers

The U.S. Court of Appeals for the Fifth Circuit vacated the Qualifying Payment Amount (QPA) benchmark used in No Surprises Act independent dispute resolution (IDR). The court ruled the methodology for calculating the QPA, often a median in-network rate, creates an unlawful "ghost rate" that unfairly skews payment determinations in favor of payers. This is a procedural win for the Texas Medical Association and other provider plaintiffs. For out-of-network claims subject to NSA disputes, the ruling removes the regulatory presumption that the QPA is the correct payment amount, potentially leading to higher award amounts for providers. Practices with pending or planned NSA disputes for services rendered after October 25, 2022, should note this shift in the legal landscape as they prepare their cases.