3 steps to take your rate request to a payer rep's boss
A rep's 3 percent cap can be the rep's own limit. Ask who can approve a larger raise, and name your open appointments in the request.
Co-founder, JotPsych
Your payer's network rep says 3 percent is the most the plan can do.
An illustration of the escalation Doral Jacobsen described in September 2026. Your rate request goes to the rep's boss next, and higher if the boss says no.
- Ask your rep who can approve a larger raise. Doral Jacobsen, whose firm negotiates with payers, gives the example of a rep named Andrea: "That person, Andrea, cannot give you more than 3%, but Andrea's boss can."
- Count what the plan loses without you. Count your clinicians, your sessions with the plan's members in the past year, and the days to your next open new-patient appointment. Jacobsen weighs how badly a payer needs your practice, because "what a payer does not want is patient disruption."
- Take your request to the rep's boss. Copy your rep. Name your next open new-patient appointment in the first paragraph. Jacobsen's rule for a denied proposal: "you need to move up the chain on the payer side."
From the Code of Federal Regulations, title 45, section 156.230, and the 2025 Letter to Issuers. Marketplace plans on the federal exchange that fall short would need to add contracted providers, so your open appointments give you a reason to ask for a higher rate.
Each plan year, from January to May 31, secret shoppers check wait times at behavioral health and primary care offices, the 2025 Letter to Issuers says. The shoppers pose as new patients, because more than half of the federal exchange's enrollees are new to their plan each year.
Each check uses the sooner of an in-person or a telehealth appointment, so your telehealth openings count. The 2027 letter doesn't change the 2025 approach to wait times.
The federal rule behind the wait-time standard also requires each Marketplace plan's network to include enough providers "that specialize in mental health and substance use disorder services."
Does your payer sell Marketplace plans on the federal exchange? Then name your open appointments in your request.
JotPsych's Payroll report, filtered to one payer, counts the sessions your clinicians delivered to that payer's members.
Book 15 minutes- Doral Jacobsen, chief executive officer of Prosper Beyond, “Strategic Revenue Cycle Workplan Design for High-Impact Payer Engagement,” workshop WS1, Medical Group Management Association (MGMA) 2026 Annual Conference, San Antonio, September 27, 2026.
- Code of Federal Regulations, title 45, section 156.230(a)(1)(ii) and (a)(2)(i)(B), network adequacy standards, via the Electronic Code of Federal Regulations, read October 5, 2026.
- Centers for Medicare & Medicaid Services, 2025 Final Letter to Issuers in the Federally-facilitated Exchanges, April 10, 2024, section on appointment wait times.
- Centers for Medicare & Medicaid Services, 2027 Final Letter to Issuers in the Federally-facilitated Exchanges, May 28, 2026: the approach to appointment wait times is unchanged from 2025.