Eliott Dear on FAIR Health vs the QPA: Why the Benchmark You Use Determines Who Wins

The Two Benchmarks

Every out-of-network payment determination in the United States is anchored to a benchmark. In state IDR, the benchmark of choice is the FAIR Health 80th percentile. In federal IDR under the No Surprises Act, the benchmark is the Qualifying Payment Amount, or QPA. These two numbers almost never agree, and the gap between them is usually the entire fight.

Eliott Dear has been running the comparison on live claims for nearly two decades. The pattern is so consistent that it determines the entire recovery profile of any non-par practice.

FAIR Health Is Independent. The QPA Is Not.

FAIR Health is a nonprofit database funded by a 2009 settlement with the New York Attorney General after UnitedHealth was caught manipulating the old Ingenix database to lowball out-of-network reimbursement. Every major insurer contributes billing data. The 80th percentile is a transparent, third-party number the insurer cannot move.

The QPA is constructed by the insurer itself. Under the federal rule, it is the median of the insurer’s own contracted rates for the service in the same geographic area, trended forward by inflation. Every input is insurer-controlled. The insurer picks which contracts to include, when they were signed, and how to apply the trend. The result is a number the payer can make smaller or larger depending on what math serves the payer’s interest.

Why the Choice Decides the Outcome

In New York state IDR, the arbitrator is presented with the FAIR Health 80th percentile as the provider’s anchor. Because it is independently verifiable and cannot be challenged as fabrication, the arbitrator has no reason to discount it. The insurer can argue that the provider should get less, but cannot argue that the benchmark itself is wrong.

In federal IDR under the No Surprises Act, the arbitrator must start from the QPA. The provider can argue for an upward departure based on credentials, complexity, and outcomes, but the anchor is the insurer’s own number. Even when providers win federal IDR, the awards cluster closer to the QPA than to FAIR Health, because the starting point pulls everything toward the payer.

What It Means for Recovery

On a typical non-par ER plastic surgery claim, the FAIR Health 80th percentile is often three to five times the QPA for the same CPT code in the same ZIP. In some markets, the spread is wider. The difference in recovery is not marginal. It is the entire economics of whether the practice collects fifty cents on the dollar or fifteen.

Eliott Dear personally verifies the FAIR Health benchmark on every Claims Assassins IDR submission. It is the same discipline a Clifford Chance structured finance associate would bring to a valuation clause in a securitization agreement. The number is either defensible or it is not. If it is defensible, the state IDR award writes itself.