Evidentiary Standards
QPA & Permitted Evidence Library
How to structure your evidentiary submission for the certified IDR entity, focusing on permitted factors and challenging the Qualifying Payment Amount (QPA).
The Federal IDR process is a "baseball-style" arbitration. Both the provider and the health plan submit a final payment offer. The certified IDR entity must select one of the two offers; they cannot split the difference or invent a third amount. Your evidence packet must convince the entity that your offer best represents the value of the qualified item or service.
1. The Role of the Qualifying Payment Amount (QPA)
The QPA is generally the plan's median contracted rate for the same or similar item or service in the same geographic region, adjusted for inflation. By law, the certified IDR entity must consider the QPA, but the QPA is not a presumed default rate.
If the QPA seems artificially low, providers should submit evidence demonstrating that the plan's QPA calculation is flawed or that the QPA does not adequately reflect the complexity or context of the specific care provided.
2. Permitted Additional Factors
In addition to the QPA, providers should submit credible information relating to the following permitted factors to support their offer:
- Provider Acuity and Experience: The level of training, experience, and quality outcomes of the provider or facility.
- Patient Acuity: The complexity of furnishing the item or service to the specific patient (e.g., severe comorbidities).
- Teaching Status and Case Mix: The teaching status, case mix, and scope of services of the facility.
- Market Share: The market share of the provider, facility, or health plan in the geographic region.
- Good Faith Contracting Efforts: Evidence of prior efforts (or lack thereof) to enter into network agreements, and the contracted rates during the previous 4 plan years.
Prohibited Factors
The certified IDR entity is expressly prohibited from considering:
- Usual and customary charges (UCR).
- The amount that would have been billed if the No Surprises Act did not apply.
- Public payor rates (e.g., Medicare, Medicaid, CHIP, TRICARE).
3. Structuring Your Submission
A high-volume, disorganized data dump is detrimental. Structure your evidence packet as a concise, indexed record. Tie every assertion directly to the clinical facts of the disputed claim or the specific permitted regulatory factors. Use clear exhibits and an executive summary that outlines exactly why your offer is the most appropriate.