PR Newswire·Aug 25, 2026, 5:30 AM ET

Fifth Circuit Rejects "Ghost Rates" in Federal QPA Calculations Under the No Surprises Act

NUTX

Nutex Health welcomed the Aug. 11, 2026, U.S. Court of Appeals for the Fifth Circuit ruling that invalidated key federal agency rules regarding Qualifying Payment Amount (QPA) calculations under the No Surprises Act (NSA).
The court found the 2021 federal rule inconsistent with the statute for allowing insurers to include nonzero unnegotiated placeholder rates (ghost rates) while excluding $0 rates, & for permitting the exclusion of bonus & incentive payments from QPA calculations.
Nutex Health stated that previous QPA methodologies artificially deflated payments by including ghost rates, forcing providers to use the costly & time-consuming Independent Dispute Resolution (IDR) process to secure fair median in-network rates.
The ruling did not affect patient protections under the NSA, meaning patients receiving out-of-network emergency care or care at in-network facilities remain responsible only for normal in-network cost-sharing & cannot be balance-billed.
The Fifth Circuit upheld the exclusion of one-off single-case agreements from QPA calculations & noted that certified IDR entities selected payments higher than insurer-calculated QPAs in approximately 85% of decided cases.
Insurers must eventually recalculate QPAs to exclude ghost rates & include bonus & incentive payments once new agency rules are promulgated, though current enforcement relief allows continued use of prior methodologies for services furnished before Oct. 1, 2026.
Future agency rules will need to address implementation questions regarding whether services must be provided more than once to be counted in the QPA & the mechanics of attributing non-fee-for-service payments to individual services.
The case is Texas Medical Association v. U.S. Department of Health and Human Services, No. 23-40605 (5th Cir. Aug. 11, 2026), & the decision may be subject to further appeal or rehearing.