The No Surprises Act, explained for surgeons.
QPA, open negotiation, and what IDR means for your practice.
The No Surprises Act removed the patient from out of network billing disputes. The patient pays the in network cost share, and the provider and the plan settle the balance between themselves. Most practices operationalized the first half and never touched the second. This page covers the provider side: why out of network claims come back short, what the qualifying payment amount is and is not, and how IDR gives you a route to the difference.
What the No Surprises Act does.
The No Surprises Act, in effect since 2022, protects patients from surprise out of network bills in specific situations: emergency care, and out of network care delivered at an in network facility. The patient pays their in network cost share, and the provider cannot balance bill them for the rest.
That protection moves the payment dispute off the patient and onto the provider and the plan. The Act replaced balance billing with a defined resolution process: open negotiation first, then federal independent dispute resolution if the parties do not agree.
Why out of network claims come back underpaid.
Because the provider can no longer bill the patient for the balance, the only counterparty is the plan, and plans tend to pay out of network claims at or near their own benchmark rather than the provider's charge. For complex surgical work, that benchmark often sits well below a defensible market rate.
The result is a steady stream of out of network explanations of benefits that pay a fraction of billed charges. For orthopedic, spine, neurosurgery, and plastics practices, where individual procedures carry significant value, the gap on a single claim can be large, and it repeats across the panel.
What the qualifying payment amount is.
The qualifying payment amount, or QPA, is generally the plan's median contracted rate for the same service in the same geographic area, calculated under federal rules. It sets the patient's cost share and anchors the plan's position in a dispute.
The QPA is the plan's number, and plans present it as the reasonable rate. It is one factor an arbitrator weighs, not the ceiling. In practice, IDR awards exceed the QPA in the large majority of determinations, which is why a QPA based payment is often a starting point rather than the final word.
Open negotiation: the required first step.
Before a dispute can reach arbitration, the Act requires a 30 business day open negotiation period. Either party starts it with the federal Open Negotiation Notice, and the window is a genuine chance to settle.
Many disputes resolve here once a plan understands the provider intends to pursue IDR. If the 30 business day period closes without agreement, the claim becomes eligible for independent dispute resolution.
Independent dispute resolution and baseball style arbitration.
Independent dispute resolution is the arbitration the Act created. It is final offer arbitration: each side submits a single payment amount, and a certified arbitrator picks one of the two. The arbitrator cannot split the difference.
That format, sometimes called baseball style arbitration, rewards the side that brings a credible, well documented number. For a surgical practice, that means an offer backed by comparable prior determinations, clinical necessity from the operative note, and the surgeon's credentials and volume on the specific procedure.
What it means for a surgical practice.
Surgical specialties feel this most, because the gap between a plan's qualifying payment amount and the market rate for a complex procedure is widest exactly where the procedure is most complex. That is also where prior determinations are most favorable, and where a documented submission is most likely to be picked.
Frequently asked
What is the No Surprises Act for providers?
The No Surprises Act protects patients from surprise out of network bills in emergencies and at in network facilities, and it replaces balance billing with a defined process between the provider and the plan: a 30 business day open negotiation, then federal independent dispute resolution if the parties do not agree.
What is independent dispute resolution in medical billing?
Independent dispute resolution, or IDR, is the federal arbitration the No Surprises Act created to settle out of network payment disputes. It is final offer arbitration: each side submits one payment amount, and a certified arbitrator selects one of the two based on the supporting evidence.
What is a qualifying payment amount?
The qualifying payment amount, or QPA, is generally the plan's median contracted rate for the same service in the same geographic area. It sets the patient's cost share and anchors the plan's position, but it is one factor an arbitrator weighs, not a ceiling. IDR awards exceed the QPA in most determinations.
Why are out of network surgical claims underpaid?
Because the No Surprises Act prevents balance billing the patient, the plan is the only counterparty, and plans tend to pay out of network claims near their own benchmark rather than the provider's charge. For complex surgical procedures, that benchmark often sits well below a defensible market rate, leaving a recoverable gap.