A single national rate can rank above median in one state and bottom quartile in another

Commercial agreements with multi-state provider organizations generally take one of two forms. In the first, the payer sets a fixed dollar amount for each service and applies it to every claim billed under the organization’s TIN, wherever the patient is located. In the second, the payer sets rates that differ by state, through separate state fee schedules or as a percentage of Medicare’s fee schedule, which carries Medicare’s geographic adjustments with it. A flat rate stays fixed while the market around it changes from state to state. A state-specific rate at least starts from local conditions, although, as the next section shows, that does not guarantee a stronger position.

Each structure appeals to a different party. Payers have reason to favor flat national rates, which simplify fee schedule administration and give them a single number to negotiate across a large provider network. Operators often accept them because one agreement covers credentialing, claims submission and payment terms for every site. That advantage matters most to telehealth organizations serving patients in many states from a centralized clinical team. The trade-off rarely surfaces during negotiation, since both parties tend to evaluate the agreement against the organization’s headquarters market or its largest state.

The posted rate files make the structure visible. When a payer reports the same dollar amount for the same service across every state where an organization operates, the agreement is almost certainly flat. The opioid treatment program operator described in the introduction illustrates the pattern. Aetna reports $99.05 for its standard established-patient visit in three states, and Meritain Health, an Aetna affiliate, reports $98.00 in the same three states. Neither amount changes at state lines. The telehealth MOUD provider holds a flat Cigna rate of $124.30 for the same visit in four states and a flat Optum rate of $128.43 in two more.

Flat rates dominate the posted data for multi-state SUD organizations. Of 1,557 combinations of organization, payer and code posted in two or more states, 70% carry an identical rate in every state. The share is highest for the medication-for-addiction bundles: 78% for G2086 and 77% for G2087. Flat structures are concentrated among the national carriers and their affiliates, ranging from 58% of multi-state combinations for Cigna to 88% for Optum. Anthem and Ambetter contract through state-based plans and show no flat rates across states in the data.

Across the 1,043 flat national rates that can be ranked in at least two states, the median gap between an organization’s best and worst state is 15 percentile points. A quarter of these rates move by 35 points or more, and 14% move by at least 50. Footprint breadth is the clearest driver of the gap. Among organizations that hold the same flat rate in three or more ranked states, the median gap more than doubles to 31.5 points, and 57% of those rates move by at least 25.

The most consequential pattern is a rate that is competitive in one state and among the lowest-paid in another. That pattern describes 15% of all flat national rates and 28% of those held in three or more states. A review of such a contract in the headquarters market would reasonably conclude that the rate is fair, even though the same rate places the organization in the bottom quarter of its market elsewhere.

State-specific rates do not close the gap on their own. When the same organization and payer have rates that differ across states, the median gap is wider still, at 28 percentile points, and 31% of those rates cross from above median to the bottom quartile. The underlying issue therefore appears to be a lack of state-level benchmarking more than the contract structure itself. Flat rates make the problem harder to detect, because the number on the fee schedule never changes.

In most states, national rates serve multi-state organizations reasonably well. Across 2,424 state-level observations of flat national rates, the median percentile is 63, and 64% of observations sit at or above the local median. The exceptions are concentrated in a small number of states where local competitors are paid noticeably more.

In Wisconsin, the median flat national rate ranks at the 2nd percentile, and 71% of observations fall in the bottom quartile. Michigan and Montana follow, with medians at the 18th and 21st percentiles and more than half of observations in the bottom quartile. Oregon stands out for the size of the shortfall. Local medians there run 41% above the flat national rates paid in the state, and nearly half of observations rank in the bottom quartile. At the other end of the range, the median flat national rate ranks at the 96th percentile in Idaho, the 93rd in the District of Columbia and the 82nd in Utah.

Many multi-state SUD organizations contract through state-level legal entities with their own TINs, a structure that might be expected to yield rates tailored to each market. The posted data shows that entity structure does change the rate an organization receives. It does not consistently improve market position, and it can open wide gaps between sister entities in the same state.

One opioid treatment network illustrates the range. Its entities receive between $55.00 and $126.40 from UnitedHealthcare for a standard established-patient visit. In New Jersey alone, one entity is paid $55.00, at the 5th percentile, while three others are paid $126.40, at the 66th. Twelve of its Ohio entities receive an identical $118.80, at the 62nd percentile. A second treatment network’s entities receive between $96.31 and $130.00 from Cigna for the same visit, and its Kentucky entities rank at the 28th, 72nd and 81st percentiles depending on which TIN billed. A third network shows the opposite pattern. Most of its entities receive an identical $430.87 from Aetna for the weekly medication bundle across Colorado, Louisiana, Missouri and Tennessee, ranking between the 85th and 91st percentile in each.

The pattern suggests entity rates often reflect when and how each entity was contracted, whether through acquisition, de novo expansion or a later amendment, more than a deliberate market-by-market strategy. An entity-level audit can therefore surface underpaid TINs that a contract-level review would miss.

National rates are not uniformly weak. The median flat national rate ranks at the 96th percentile in Idaho, the 93rd in the District of Columbia and the 81st in Illinois, and local medians in those states run 17% to 23% below the national rates paid there. Arizona, New York and New Jersey follow closely, each with a median flat national rate between the 76th and 79th percentile. As a group, the national rates that rank in the bottom quartile in Wisconsin, Michigan and Montana rank near the top of the market in these states, a divergence that a single contract-level review cannot capture.

Outperformance is common, but it coexists with underperformance in the same portfolios. More than half of flat national rates (52%) reach the top quartile in at least one state, and 40% of all state-level observations rank there. Among organizations that hold the same rate in three or more states, however, 28% of those rates rank above the median in one state and in the bottom quartile in another. A portfolio-level review blends these markets into an average that looks acceptable, and operators cannot see where the rate is working and where it is not.

Payer behavior shapes how far a national rate drifts. Cigna’s flat national rates are the most consistent in the data, with a median gap of 7 percentile points between an organization’s best and worst state and only 1% crossing from above median to the bottom quartile. For UnitedHealthcare, Aetna, Optum and Meritain, the gaps range from 13 to 21 points, and 8% to 21% of rates cross. Consistency is not the same as outperformance, however: 35% of Cigna’s flat rates reach the top quartile somewhere, compared with 45% to 59% for the other payers. The telehealth MOUD provider in this analysis illustrates both sides. Its Cigna rate of $124.30 for a standard established-patient visit ranks at the 85th percentile in Tennessee, the 76th in Texas, the 73rd in Ohio and the 28th in Maine. Its Aetna rate for the same visit ranks at the 6th percentile in Tennessee and the 3rd in Texas.

These results set limits on a sound response. Replacing a national agreement with state-specific terms across the board could lower reimbursement in the states where the national rate performs best. The more defensible course is to identify, payer by payer, the states where a national rate outperforms and protect them at renewal. State-specific terms are worth pursuing only where the rate ranks in the bottom quartile and volume justifies the effort. Both decisions depend on the same state-level benchmark.

The central implication of this analysis is that a national contract cannot be evaluated as a single number. For a multi-state SUD organization, the same agreement represents a series of distinct market positions, competitive in some states and in the bottom quartile in others. The organization’s overall reimbursement depends on how those positions line up with the states where its volume and growth are concentrated. Most operators review these agreements against their headquarters market or their largest state, which tends to confirm that the rate is fair. The states where the rate underperforms are often newer or smaller markets that receive little attention at renewal, and because the rate never changes on the fee schedule, nothing prompts a second look.

Seeing the contract as a portfolio changes the negotiation. A multi-state operator brings more leverage to a national renewal than any single site could. State-level benchmarks let it direct that leverage at the specific markets where the rate falls short, requesting separate fee schedule exhibits for the lowest-ranked, highest-volume states and keeping the national rate where it outperforms. A narrow, evidence-based request of this kind is the type most likely to succeed. In an August 2026 MGMA poll, medical groups that had secured recent commercial increases most often cited market position and benchmarking data as deciding factors.¹ The same discipline applies to rates that already differ by state, which in this analysis vary across markets at least as widely as flat national rates.

The portfolio extends to legal structure as well. Organizations that grow through acquisition or de novo expansion often accumulate entities contracted at different times on different terms, and the sister-entity gaps documented in section 04 show how far those terms can drift within a single state. Decisions about which entity bills for which sites, and whether an acquired entity should move onto the organization’s national contract, have direct reimbursement consequences. Those consequences become visible only when rates are compared entity by entity and state by state.

Contracts alone cannot confirm any of these positions. Many organizations hold several posted rates for the same code with the same payer. Only remittance data shows whether claims are paid at the contracted amount, and which of several posted rates was actually applied. For operators, the state-level benchmark and the state-level payment record are two halves of the same view. Together they show where a national agreement is working and where it is quietly costing the organization revenue.

For investors, the same lens belongs in diligence on multi-state SUD platforms. A platform’s national rates can look competitive in aggregate while ranking in the bottom quartile in the states expected to drive growth. Integration plans that move acquired entities onto a national contract may raise reimbursement in some markets and lower it in others.