In a lawsuit filed Sept. 30 in the U.S. District Court in the Eastern District of Texas, UnitedHealthcare argues CMS is poised to downgrade its star ratings “based upon a single phone call that lasted less than [10] minutes.”
CMS determines star ratings for MA plans based on several clinical quality and customer service metrics. The agency rates plans’ call center adequacy by placing test calls from secret shoppers.
For a call to be included in CMS’ sample, the test caller must ask an introductory question, and the customer service representative must respond, UnitedHealthcare said in its lawsuit. The company alleged CMS is including a call in its ratings where the required introductory question was not asked.
“Because 100% success is required to be awarded 5 Stars on the call center measure, CMS’ decisions regarding whether and how to score each call included in the study can have a material impact on plan performance on the call center measure specifically, as well as on a plan’s overall Star Rating,” UnitedHealthcare’s attorneys wrote.
UnitedHealthcare asked the court to have CMS throw out the disputed call and require CMS to recalculate its star ratings before the ratings are published Oct. 10.
Elevance Health previously challenged the inclusion of a phone call in its star ratings. The company alleged the disputed test call never connected and said it lost $190 million in bonus payments as a result of the call.
CMS eventually ruled in Elevance’s favor to remove the call from its calculations.
In June, CMS recalculated Medicare Advantage plans’ star ratings after SCAN Health Plan and Elevance Health challenged the methodology used to calculate the ratings.
Medicare Advantage star ratings determine bonus payment eligibility for MA plans and guide enrollment decisions for beneficiaries.
Open enrollment in 2025 Medicare Advantage plans begins Oct. 15 and ends Dec. 7.
Becker’s has reached out to UnitedHealthcare and CMS for comment and will update this article if more information becomes available.
