Answers / QPA vs billed charges

QPA vs billed charges vs Medicare vs IDR awards

The four numbers, defined

Billed charges. The provider's full list price for the service. On an out-of-network claim nobody expects this number to be paid in full, and in federal arbitration it carries no formal weight.

Medicare rate. What Medicare pays for the same code. It is public, standardized, and usually the lowest of the four. Commercial payers often describe out-of-network payments as a percentage of Medicare, but the No Surprises Act does not use Medicare as its benchmark.

The QPA. The plan's median contracted rate for the same or similar service, in the same geographic region, as of January 31, 2019, indexed each year by consumer price index factors published by the IRS. For services furnished in 2026, a 2019 base QPA is the 2019 median multiplied by 1.2805070065 (IRS Notice 2025-65). The QPA sets the patient's cost sharing, and it is the benchmark the arbitrator must consider. The full mechanics are in the methodology guide, and the QPA calculator does the indexing.

The IDR award. Federal independent dispute resolution is baseball style: each side submits one offer and the arbitrator picks one. The award is the number that actually moves money.

What the published record shows

CMS publishes the outcome of every federal IDR dispute. Three patterns matter here:

• Payers anchor at the QPA. The median payer offer in the public use files is 1.0 times the QPA. The initial payment that arrives with the remittance is typically built on the same anchor.
• Arbitrators do not stay there. Providers win 85.8 percent of federal IDR disputes that reach a decision, and the median award is 4.7 times the qualifying payment amount, based on 3.39 million disputes in the federal public use files.
• The gap is structural. A benchmark built from 2019 median in-network rates, indexed only by general inflation, sits well below what arbitrators find reasonable for out-of-network care in most specialties. The win rates and multiples have held across three years of published data.

CMS federal IDR public use files, 2023 through 2025. Explore the full record at idrexplorer.com.

What the arbitrator may and may not consider

The rules require the arbitrator to consider the QPA, plus credible information about the case: the provider's training and experience, the patient's acuity and the complexity of the service, the market share of the parties, the facility's teaching status and case mix, good faith efforts to go in network, and prior contract history between the parties.

Three things are off the table by rule. The arbitrator may not consider billed charges, usual and customary rates, or public program rates such as Medicare and Medicaid. So neither the biggest number on the claim nor the smallest one is formally in the room. The fight is the QPA against the provider's evidence, which is exactly why the 4.7 multiple is so striking.

What the gap means for out-of-network providers

First, check the anchor. The plan must disclose the QPA with its initial payment or denial. The indexing step is public arithmetic: run the base rate through the published factors and confirm the number is at least internally consistent.

Second, treat the initial payment as an opening offer. Accepting a payment built on 1.0 times the QPA, when the median decided award runs 4.7 times the QPA, leaves most of the claim's value unclaimed. The deadlines are short: open negotiation starts within 30 business days of the initial payment, and the arbitration window follows immediately.

Third, price the process before you commit. Filing costs real money: a $15 federal administrative fee per party per dispute, plus the certified IDR entity's fee, which is returned to the winning party. Most billing vendors and law firms that file for providers charge contingency, typically 15 to 25 percent of the recovery. Lido IDR files and manages disputes for a flat fee per arbitration instead. Either way, the first step is the same: estimate what your claims would actually win at idrcalculator.com, then compare that against the payer's QPA anchored offer.