Ghost Rates Under the No Surprises Act: How Insurer Calculations Artificially Lower the Qualifying Payment Amount.

The United States No Surprises Act removed patients from many payment disputes between nonparticipating clinicians and insurers while giving substantial influence to the qualifying payment amount (QPA) calculated by the insurer. This editorial examines whether a federally authorized payment benchmark calculated by the party responsible for payment, using data unavailable to the opposing party, can satisfy basic requirements of legitimacy, reproducibility, and accountability. On August 11, 2026, the en banc United States Court of Appeals for the Fifth Circuit held that the challenged federal methodology was inconsistent with the statute because it required the inclusion of nonnegotiated "ghost rates." The court concluded that these rates produced artificially low QPAs. Federal independent dispute resolution data published by the Centers for Medicare & Medicaid Services for the third and fourth quarters of 2025 show that providers prevailed in 84% of determinations that were fully contested and did not involve default, and that selected offers exceeded the QPA in approximately 87% of reported comparisons. These results do not establish that every provider offer was reasonable or that ghost rates explain every award. They demonstrate the need for transparent benchmark construction. We recommend disclosure of QPA methodology and rate populations, confidential access by independent auditors to rate-level data, and independent reproduction of disputed QPAs.