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.

Nate Peereboom
Co-founder, JotPsych

Your payer's network rep says 3 percent is the most the plan can do. The 3 percent can be the rep's limit, not the plan's. Don't stop at the rep.

1. 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." Above the rep, Jacobsen named a vice president, the chief executive, or the chief medical officer.
2. 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."
3. 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."

Since January 1, 2025, a federal rule has required Marketplace plans on the federal exchange to meet appointment wait-time standards. For behavioral health, the standard is an appointment within 10 business days. The Centers for Medicare & Medicaid Services' 2025 Letter to Issuers requires plans to meet that standard at least 90 percent of the time.

Secret shoppers posing as new patients test the standard, and insurers that fall short "would need to add more contracted providers to the network," the 2025 letter says. The 2027 Letter to Issuers doesn't change the standard.

If your payer sells Marketplace plans on the federal exchange, your open appointments help those plans meet the standard. Name your open appointments in your request.