The 5th U.S. Circuit Court of Appeals on Aug. 11 struck down key federal rules governing how insurers calculate the qualified payment amount (QPA), a benchmark used for cost-sharing and resolving out-of-network payment disputes under the No Surprises Act (NSA). The court affirmed portions of a district court ruling that insurers cannot include “ghost rates” – defined as contracted rates for services that providers do not offer – or exclude bonus and incentive payments when calculating QPAs, finding these practices can artificially lower payment amounts. The court, however, upheld insurers’ ability to exclude certain one-off agreements. The court also granted agency discretion over whether insurance companies can use existing QPAs until new ones are determined. The Departments of Health and Human Services, Treasury, and Labor are reviewing the opinion and anticipate issuing guidance shortly.
Meanwhile, changes are coming to the NSA’s Independent Dispute Resolution (IDR) process. The IDR final rule released in May 2026 introduced a new IDR Gateway that will serve as the central portal for all open negotiation and IDR-related activities, including dispute initiation. All potential users of the IDR Gateway can begin creating accounts on Sept. 15. The departments also are hosting a webinar from 1 to 2 p.m. EST on Sept. 15 to orient users to the Gateway.
In a related development, AAOMS recently thanked House and Senate sponsors of the No Surprises Enforcement Act, which aims to strengthen accountability by increasing penalties for health insurers that fail to pay providers in a timely manner following the IDR process. AAOMS has updated its No Surprises Act resources to include guidance for the new IDR final rule. OMSs are encouraged to remain up-to-date on changes to the NSA via CMS and AAOMS resources.
