Benchmark-Outcome Separation in Federal Independent Dispute Resolution: A Descriptive Analysis of Qualifying Payment...

Introduction The Qualifying Payment Amount (QPA) is an issuer-calculated median in-network contracted rate defined by statute and regulation and is a central reference point in the federal No Surprises Act independent dispute resolution (IDR) process. Whether reported QPA behaves as a close descriptive comparator for observed federal IDR payment determinations in specific procedural domains remains an empirical question. The objective of this study was to evaluate the relationship between reported QPA and observed adjudicated payment determinations in federal IDR disputes involving Current Procedural Terminology (CPT) 13100-13153 (complex repair and layered closure codes) and to introduce the Adjudicated Rate Index (ARI) as a descriptive cohort-level summary of adjudicated-payment-to-QPA multiples. Methods Centers for Medicare & Medicaid Services (CMS) federal IDR public use files were analyzed for disputes involving CPT 13100-13153. For each dispute, a case-level payment multiple was calculated as the selected payment divided by the reported QPA. ARI was defined as the median of these case-level multiples within a specified cohort. Prespecified analyses included all analytic cases, provider/facility-prevailing disputes, plan-prevailing disputes, quarter-level cohorts, and CPT subgroup cohorts. The analysis was descriptive and did not treat adjudicated payment as a normative payment standard, measure of clinical value, or predictor of individual dispute outcomes. Results Across prespecified analytic views, reported QPA and observed adjudicated payment determinations were not empirically interchangeable within this complex repair code family. In the pooled 2023 quarter 1 (Q1)-2025 quarter 2 (Q2) provider/facility-prevailing cohort, the median adjudicated-payment-to-QPA multiple was 28.73×. Across all analytic cases with available QPA-multiple data, the median multiple was 22.41×. Plan-prevailing disputes clustered near QPA parity, supporting the interpretation of the source field as reporting QPA-relative payment outcomes. Conclusion In CMS-reported federal IDR disputes involving CPT 13100-13153, reported QPA and observed adjudicated payment determinations did not behave as interchangeable descriptive reimbursement measures within the analyzed cohort. ARI provides a domain-specific summary of observed adjudicated-payment-to-QPA relationships, but it does not replace QPA in the statutory framework, establish payment adequacy, or predict individual dispute outcomes. Further analyses across other procedural domains, specialties, regions, payer types, and data sources are needed to assess generalizability.