What the court actually did
On August 11, 2026, the full U.S. Court of Appeals for the Fifth Circuit, sitting en banc, ruled in Texas Medical Association v. HHS (No. 23-40605) that federal agencies' methodology for calculating the "qualifying payment amount," or QPA, under the No Surprises Act is partly unlawful. The court sided with the Texas Medical Association and other provider plaintiffs on two of the three formula challenges they raised, as STAT News reported.
It's the latest round in a fight that has run since the No Surprises Act's 2022 implementation, and it lands squarely on the number that decides how out-of-network billing disputes get resolved — including the disputes radiology groups file every time a scan is read out-of-network and a payer disagrees on price.
What the QPA is, and why it's the fulcrum
The QPA is meant to represent the median rate a health plan pays in-network for a given service in a given market. Under the No Surprises Act, it does two jobs: it sets the floor for the initial payment an insurer must send on an out-of-network claim, and it's the benchmark independent arbitrators weigh most heavily when a provider disputes that payment through the federal independent dispute resolution (IDR) process. A lower QPA means a lower starting offer on every claim — disputed or not.
Providers have argued since the rule's earliest days that the government's calculation method quietly thumbed the scale toward insurers. This ruling agrees, on two specific points.
Two wins for providers, one loss
First, the court struck down insurers' use of "ghost rates" — contracted rates for services a provider doesn't actually furnish, and therefore never negotiates. Because nobody bargains over a price for a service they don't perform, these rates can sit near $0 or $1, and folding them into the median in-network rate quietly pulls the whole QPA down, as Healthcare Dive detailed. The court held that only rates for services actually "provided by a provider" satisfy the statute, so ghost rates must be excluded entirely, not just the $0 ones the agencies' earlier guidance had carved out.
Second, the court ruled that bonus, incentive, and risk-sharing payments — a real part of many provider contracts — must be counted toward the QPA. Excluding them, the majority found, contradicted the statute's "total maximum payment" language.
Providers didn't win everything. The court upheld the agencies' decision to exclude one-off single-case agreements — arrangements common in air-ambulance billing — from the calculation, agreeing those aren't the kind of standing "contracted rates" the formula is supposed to reflect.
| QPA component | Before this ruling | After this ruling |
|---|---|---|
| Ghost rates (unnegotiated, often $0–$1) | Included, except explicit $0 rates | Excluded entirely |
| Bonus / incentive / risk-sharing pay | Excluded from the median | Must be included |
| Single-case agreements (e.g., air ambulance) | Excluded | Still excluded (upheld) |
Why radiology has more at stake than most specialties
Radiology isn't a bystander in this fight. It's the second-most-disputed specialty in the federal IDR process, behind only emergency medicine — accounting for roughly 19% of payment determinations in the first half of 2025 and 15% in the second half, against emergency medicine's 45% and 52%, according to CMS data reported by Radiology Business. Hospital-based specialties like radiology are disproportionately exposed to out-of-network billing in the first place, because a patient can choose an in-network hospital and still be read by an out-of-network radiology group without ever knowing it.
Radiology also does unusually well once a dispute reaches arbitration. In the first half of 2024, radiology's median prevailing provider offer landed at roughly 600% of the QPA — up from about 559% at the end of 2023 — according to Georgetown University's Center on Health Insurance Reforms, which also found providers across specialties winning 83–88% of resolved disputes that year. The Fifth Circuit's own opinion cites similarly striking figures: IDR volume has run 84 times higher than agencies originally forecast, providers have prevailed in more than 80% of arbitrations, and arbitrators have picked a rate above the QPA in 85% of cases.
A higher, more accurately calculated QPA cuts both ways for a specialty that already wins big relative to that benchmark: it raises the floor insurers must pay on every out-of-network claim — including the vast majority that never go to arbitration — but it also raises the number a radiology group has to beat to win a dispute. Either way, the number both sides are negotiating against is about to move, and it's moving in a direction provider advocacy groups have long pushed for.
What's still unsettled
This is a legal win, not a rate increase that shows up in next month's remittance. The court affirmed vacating the challenged parts of the QPA methodology, but it also rejected the idea that "practical problems" justified keeping an unlawful formula in place — while still leaving room for agencies to use enforcement discretion so the transition doesn't cause immediate disruption. The Departments of Health and Human Services, Labor, and Treasury now have to write a new, statute-compliant methodology, and no fixed deadline has been set for when that happens or when it takes effect for any individual group's contracts and disputes. A further appeal also remains possible.
For a radiology group weighing near-term budget decisions, that means the reimbursement side of the ledger just moved in a favorable direction on paper, but on a timeline nobody has committed to yet.
The lever practices can pull today: cost, not just leverage
With the revenue side of out-of-network reimbursement still moving through rulemaking and possible further litigation, the cost side of the margin equation is the one a practice can control right now. Reporting turnaround and cost per study don't have to wait on a federal rule change. This is where AI-assisted CT reporting fits: it produces a structured draft report for every study, xAID's in-house radiologist reviews each preliminary, and the report reaches the client's reading radiologist ready-to-sign — cutting the cost and turnaround of producing a report without touching who has final authority over it. It doesn't settle a payer dispute, but it protects margin while the QPA fight plays out in Washington and the courts.
Frequently asked questions
What is the qualifying payment amount (QPA) under the No Surprises Act?
The QPA is generally the median contracted in-network rate a health plan pays for a given service in a given geographic area. Under the No Surprises Act, it is the number insurers must use as the floor for their initial out-of-network payment and the benchmark that federal arbitrators weigh most heavily when resolving billing disputes through independent dispute resolution (IDR).
What did the Fifth Circuit rule on the QPA formula, and when?
On August 11, 2026, the full Fifth Circuit Court of Appeals, sitting en banc in Texas Medical Association v. HHS (No. 23-40605), ruled that federal agencies' methodology for calculating the QPA was partly unlawful. The court held that insurers must exclude non-negotiated 'ghost rates' from the calculation and must include bonus, incentive, and risk-sharing payments. It upheld one part of the government's approach: excluding one-off single-case agreements, common in air-ambulance billing, from the formula.
What are 'ghost rates' and why do they matter?
Ghost rates are contracted rates for services a provider never actually furnishes and therefore never negotiates — sometimes as low as $0 or $1. Because they are not real market prices, including them in the median calculation artificially depresses the QPA. The court found that only the government's rate for services actually "provided by a provider" satisfies the statute, so ghost rates must be excluded entirely.
Does the ruling immediately raise what radiology groups get paid for out-of-network claims?
Not immediately. The court affirmed vacating the challenged provisions, but federal agencies can use enforcement discretion to keep existing QPAs in place while they write a new, compliant rule, and no fixed deadline has been set. An appeal is also possible. The legal trend favors providers, but the timeline for a recalculated, higher QPA to actually change contracted and arbitrated rates is unsettled.
What can radiology groups do about reimbursement uncertainty right now?
Because the revenue side of the ledger is contested and moving slowly through rulemaking and litigation, groups can protect margin in the meantime by controlling the cost side: reporting turnaround and cost per study. AI-assisted CT reporting, with a radiologist reviewing every report, is one such lever — it does not resolve a payer dispute, but it lowers the cost of producing each read while the QPA fight plays out.
Source: Radiology Business, STAT News, and Healthcare Dive on the Fifth Circuit's August 11, 2026 en banc opinion in Texas Medical Association v. HHS (No. 23-40605); IDR dispute-volume and win-rate figures per the court's opinion and Georgetown University's Center on Health Insurance Reforms; radiology's share of IDR disputes per CMS data reported by Radiology Business. Figures are rounded as reported.