{"id":13166,"date":"2024-10-07T11:29:58","date_gmt":"2024-10-07T11:29:58","guid":{"rendered":"https:\/\/distilinfo.com\/healthplan\/?p=13166"},"modified":"2024-10-07T11:29:58","modified_gmt":"2024-10-07T11:29:58","slug":"unitedhealthcare-battles-cms","status":"publish","type":"post","link":"https:\/\/distilinfo.com\/healthplan\/unitedhealthcare-battles-cms\/","title":{"rendered":"UnitedHealthcare Battles CMS for Fair Star Ratings"},"content":{"rendered":"\r\n<div id=\"rank-math-toc\" class=\"wp-block-rank-math-toc-block has-pale-ocean-gradient-background has-background\"><nav>\r\n<ul>\r\n<li><a href=\"#introduction\">Introduction<\/a><\/li>\r\n<li><a href=\"#background-on-medicare-advantage-star-ratings\">Background on Medicare Advantage Star Ratings<\/a><\/li>\r\n<li><a href=\"#the-dispute-one-phone-call\">The Dispute: One Phone Call<\/a><\/li>\r\n<li><a href=\"#united-healthcares-legal-argument\">UnitedHealthcare&#8217;s Legal Argument<\/a><\/li>\r\n<li><a href=\"#past-precedents-elevance-healths-experience\">Past Precedents: Elevance Health\u2019s Experience<\/a><\/li>\r\n<li><a href=\"#impact-on-medicare-advantage-plans\">Impact on Medicare Advantage Plans<\/a><\/li>\r\n<li><a href=\"#what-happens-next\">What Happens Next?<\/a><\/li>\r\n<li><a href=\"#conclusion\">Conclusion<\/a><\/li>\r\n<li><a href=\"#fa-qs\">FAQs<\/a>\r\n<ul>\r\n<li><a href=\"#1-why-is-united-healthcare-suing-cms\">1. Why is UnitedHealthcare suing CMS?<\/a><\/li>\r\n<li><a href=\"#2-what-are-medicare-advantage-star-ratings\">2. What are Medicare Advantage star ratings?<\/a><\/li>\r\n<li><a href=\"#3-how-can-one-phone-call-affect-star-ratings\">3. How can one phone call affect star ratings?<\/a><\/li>\r\n<li><a href=\"#4-what-impact-could-this-lawsuit-have\">4. What impact could this lawsuit have?<\/a><\/li>\r\n<\/ul>\r\n<\/li>\r\n<\/ul>\r\n<\/nav><\/div>\r\n\r\n\r\n\r\n<h2 id=\"introduction\" class=\"wp-block-heading\">Introduction<\/h2>\r\n\r\n\r\n\r\n<p>In a bold legal move, UnitedHealthcare is suing the <a href=\"https:\/\/finance.yahoo.com\/news\/unitedhealth-sues-cms-over-medicare-105958280.html\" target=\"_blank\" rel=\"noopener\">Centers for Medicare &amp; Medicaid Services (CMS<\/a>) over a decision that could impact the company\u2019s Medicare Advantage (MA) star ratings. The lawsuit, filed on September 30, 2024, stems from a single phone call that <a href=\"https:\/\/www.statnews.com\/2024\/10\/03\/united-health-sues-cms-over-downgraded-medicare-advantage-ratings\/\" target=\"_blank\" rel=\"noopener\">UnitedHealthcare<\/a> argues is unjustly affecting its star rating performance. UnitedHealthcare&#8217;s case shines a light on the critical importance of CMS star ratings in determining bonus payments and influencing beneficiary enrollment decisions for Medicare Advantage plans.<\/p>\r\n\r\n\r\n\r\n<h2 id=\"background-on-medicare-advantage-star-ratings\" class=\"wp-block-heading\">Background on Medicare Advantage Star Ratings<\/h2>\r\n\r\n\r\n\r\n<p>Medicare Advantage star ratings are a key factor in evaluating the quality of care provided by MA plans. These ratings are determined based on several criteria, including clinical outcomes, patient experience, and customer service metrics. One of the components influencing these ratings is a plan\u2019s performance in call center operations, which includes metrics like response time, accuracy, and customer satisfaction.<\/p>\r\n\r\n\r\n\r\n<p>CMS conducts secret shopper test calls to evaluate the adequacy of Medicare Advantage plans\u2019 call centers. The results of these test calls can have significant financial implications for insurance companies. Plans with higher star ratings receive bonus payments and are more attractive to beneficiaries during the annual open enrollment period. Conversely, lower ratings can result in financial penalties and decreased enrollment.<\/p>\r\n\r\n\r\n\r\n<h2 id=\"the-dispute-one-phone-call\" class=\"wp-block-heading\">The Dispute: One Phone Call<\/h2>\r\n\r\n\r\n\r\n<p>UnitedHealthcare&#8217;s lawsuit is centered around a single test call placed by a CMS secret shopper. The company claims that this one phone call, which lasted less than ten minutes, is being used to downgrade its Medicare Advantage star rating.<\/p>\r\n\r\n\r\n\r\n<p>According to the lawsuit, the test call failed to meet CMS&#8217; own standards for inclusion in the star ratings assessment. Specifically, UnitedHealthcare argues that the introductory question required by CMS was never asked during the call. Despite this, CMS is allegedly counting the call against UnitedHealthcare&#8217;s performance, which could have a substantial impact on the company\u2019s overall star rating.<\/p>\r\n\r\n\r\n\r\n<p>Because achieving a 5-star rating requires a 100% success rate in certain measures, such as call center operations, the inclusion of even a single flawed call could result in a downgraded star rating for UnitedHealthcare. The company contends that this single instance should not be allowed to disproportionately affect its performance in such a critical area.<\/p>\r\n\r\n\r\n\r\n<h2 id=\"united-healthcares-legal-argument\" class=\"wp-block-heading\">UnitedHealthcare&#8217;s Legal Argument<\/h2>\r\n\r\n\r\n\r\n<p>In its lawsuit, UnitedHealthcare is asking the U.S. District Court for the Eastern District of Texas to intervene before CMS publishes its final star ratings on October 10, 2024. UnitedHealthcare&#8217;s attorneys argue that the disputed phone call does not meet CMS&#8217; criteria for inclusion in the star rating evaluation and should be discarded.<\/p>\r\n\r\n\r\n\r\n<p>The lawsuit seeks a court order requiring CMS to exclude the phone call from its calculations and to recalculate UnitedHealthcare&#8217;s star ratings without the inclusion of this disputed call. The stakes are high for UnitedHealthcare, as the star rating directly impacts the company\u2019s ability to receive bonus payments and retain enrollment advantages.<\/p>\r\n\r\n\r\n\r\n<p>&#8220;Because 100% success is required to be awarded 5 Stars on the call center measure, CMS&#8217; 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\u2019s overall Star Rating,&#8221; UnitedHealthcare&#8217;s attorneys wrote in the filing.<\/p>\r\n\r\n\r\n\r\n<h2 id=\"past-precedents-elevance-healths-experience\" class=\"wp-block-heading\">Past Precedents: Elevance Health\u2019s Experience<\/h2>\r\n\r\n\r\n\r\n<p>This is not the first time a dispute over a single phone call has led to litigation involving CMS&#8217; star ratings. Elevance Health, another major insurer, previously challenged CMS over the inclusion of a disputed test call in its star rating evaluation.<\/p>\r\n\r\n\r\n\r\n<p>In that case, Elevance Health claimed that a test call never actually connected, yet CMS included it in the company\u2019s rating assessment. As a result, Elevance Health argued that it lost out on approximately $190 million in bonus payments. After an intense legal battle, CMS eventually ruled in Elevance Health\u2019s favor and agreed to remove the call from the star ratings calculation.<\/p>\r\n\r\n\r\n\r\n<p>This precedent gives UnitedHealthcare hope that the court will side with them and grant relief by forcing CMS to recalculate its ratings without the disputed call. The Elevance Health case highlights the significant financial impact that star ratings can have on insurers, and UnitedHealthcare is hoping for a similar outcome.<\/p>\r\n\r\n\r\n\r\n<h2 id=\"impact-on-medicare-advantage-plans\" class=\"wp-block-heading\">Impact on Medicare Advantage Plans<\/h2>\r\n\r\n\r\n\r\n<p>The Medicare Advantage star ratings system plays a crucial role in the financial health of insurance companies. Plans that receive higher ratings are eligible for increased bonus payments from the government and enjoy a competitive edge during the annual open enrollment period. On the other hand, lower-rated plans may lose out on bonuses and see reduced enrollment numbers, affecting their revenue and market position.<\/p>\r\n\r\n\r\n\r\n<p>UnitedHealthcare\u2019s star rating could drop if the disputed call remains part of CMS&#8217; evaluation, which could result in the loss of significant financial rewards. The open enrollment period for 2025 Medicare Advantage plans begins on October 15, 2024, making the timing of this lawsuit crucial. The outcome will not only affect UnitedHealthcare but could also set a precedent for how CMS handles similar disputes in the future.<\/p>\r\n\r\n\r\n\r\n<h2 id=\"what-happens-next\" class=\"wp-block-heading\">What Happens Next?<\/h2>\r\n\r\n\r\n\r\n<p>UnitedHealthcare&#8217;s lawsuit is currently pending in the U.S. District Court for the Eastern District of Texas. The company is seeking an emergency injunction to prevent CMS from publishing the final star ratings until the disputed phone call is removed from the assessment.<\/p>\r\n\r\n\r\n\r\n<p>CMS has yet to publicly comment on the case, and the outcome remains uncertain. If the court sides with UnitedHealthcare, it could force CMS to make significant changes to its star rating evaluation process, particularly regarding how test calls are scored. Additionally, this case may encourage other insurers to challenge CMS&#8217; decisions when they believe the star rating process has been unfairly applied.<\/p>\r\n\r\n\r\n\r\n<h2 id=\"conclusion\" class=\"wp-block-heading\">Conclusion<\/h2>\r\n\r\n\r\n\r\n<p>The lawsuit between UnitedHealthcare and CMS underscores the high stakes involved in the Medicare Advantage star ratings system. A single phone call, lasting less than ten minutes, could have a profound impact on an insurer\u2019s financial performance and market position. As UnitedHealthcare fights to preserve its star rating, the case highlights the critical importance of accuracy and fairness in CMS&#8217; rating methodology. With billions of dollars and the well-being of Medicare beneficiaries at stake, the outcome of this lawsuit could have far-reaching implications for the entire Medicare Advantage program.<\/p>\r\n\r\n\r\n\r\n<p><span data-teams=\"true\"><span class=\"ui-provider a b c d e f g h i j k l m n o p q r s t u v w x y z ab ac ae af ag ah ai aj ak\" dir=\"ltr\">Discover the latest <a id=\"menur22s\" class=\"fui-Link ___1q1shib f2hkw1w f3rmtva f1ewtqcl fyind8e f1k6fduh f1w7gpdv fk6fouc fjoy568 figsok6 f1s184ao f1mk8lai fnbmjn9 f1o700av f13mvf36 f1cmlufx f9n3di6 f1ids18y f1tx3yz7 f1deo86v f1eh06m1 f1iescvh fhgqx19 f1olyrje f1p93eir f1nev41a f1h8hb77 f1lqvz6u f10aw75t fsle3fq f17ae5zn\" title=\"https:\/\/distilinfo.com\/healthplan\/\" href=\"https:\/\/distilinfo.com\/healthplan\/\" target=\"_blank\" rel=\"noreferrer noopener\" aria-label=\"Link payers&#039; news updates\"><strong>payers&#8217; news updates<\/strong><\/a> with a single click. Follow <a id=\"menur22u\" class=\"fui-Link ___1q1shib f2hkw1w f3rmtva f1ewtqcl fyind8e f1k6fduh f1w7gpdv fk6fouc fjoy568 figsok6 f1s184ao f1mk8lai fnbmjn9 f1o700av f13mvf36 f1cmlufx f9n3di6 f1ids18y f1tx3yz7 f1deo86v f1eh06m1 f1iescvh fhgqx19 f1olyrje f1p93eir f1nev41a f1h8hb77 f1lqvz6u f10aw75t fsle3fq f17ae5zn\" title=\"https:\/\/distilinfo.com\/healthplan\/\" href=\"https:\/\/distilinfo.com\/healthplan\/\" target=\"_blank\" rel=\"noreferrer noopener\" aria-label=\"Link DistilINFO HealthPlan\">DistilINFO HealthPlan<\/a> and stay ahead with updates. Join our community today!<\/span><\/span><\/p>\r\n\r\n\r\n\r\n<h2 id=\"fa-qs\" class=\"wp-block-heading\">FAQs<\/h2>\r\n\r\n\r\n\r\n<h3 id=\"1-why-is-united-healthcare-suing-cms\" class=\"wp-block-heading\">1. Why is UnitedHealthcare suing CMS?<\/h3>\r\n\r\n\r\n\r\n<p>A. UnitedHealthcare is suing CMS because the agency is allegedly using a single phone call to downgrade its star ratings, which could significantly impact the company\u2019s financial performance.<\/p>\r\n\r\n\r\n\r\n<h3 id=\"2-what-are-medicare-advantage-star-ratings\" class=\"wp-block-heading\">2. What are Medicare Advantage star ratings?<\/h3>\r\n\r\n\r\n\r\n<p>A. Medicare Advantage star ratings are a system used by CMS to evaluate the performance of MA plans based on clinical outcomes, patient experience, and customer service, among other factors.<\/p>\r\n\r\n\r\n\r\n<h3 id=\"3-how-can-one-phone-call-affect-star-ratings\" class=\"wp-block-heading\">3. How can one phone call affect star ratings?<\/h3>\r\n\r\n\r\n\r\n<p>A. A single phone call can impact star ratings if it is part of CMS&#8217; secret shopper test calls used to evaluate customer service. UnitedHealthcare argues that the phone call in question did not meet CMS&#8217; own criteria for inclusion.<\/p>\r\n\r\n\r\n\r\n<h3 id=\"4-what-impact-could-this-lawsuit-have\" class=\"wp-block-heading\">4. What impact could this lawsuit have?<\/h3>\r\n\r\n\r\n\r\n<p>A. The lawsuit could result in CMS recalculating UnitedHealthcare\u2019s star ratings, which could prevent the company from losing out on bonus payments and maintain its competitive position during open enrollment.<\/p>\r\n","protected":false},"excerpt":{"rendered":"<p>Introduction In a bold legal move, UnitedHealthcare is suing the Centers for Medicare &amp; Medicaid Services (CMS) over a decision&#8230; <a href=\"https:\/\/distilinfo.com\/healthplan\/unitedhealthcare-battles-cms\/\" style=\"white-space: nowrap;\">Continue Reading <i class=\"fas fa-long-arrow-alt-right\" style=\"vertical-align: middle;\"><\/i><\/a><\/p>\n","protected":false},"author":1,"featured_media":12247,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"rank_math_lock_modified_date":false,"_genesis_hide_title":false,"_genesis_hide_breadcrumbs":false,"_genesis_hide_singular_image":false,"_genesis_hide_footer_widgets":false,"_genesis_custom_body_class":"","_genesis_custom_post_class":"","_genesis_layout":"","footnotes":""},"categories":[1],"tags":[81],"class_list":{"0":"post-13166","1":"post","2":"type-post","3":"status-publish","4":"format-standard","5":"has-post-thumbnail","7":"category-distilinfo-originals","8":"tag-unitedhealthcare","9":"entry"},"_links":{"self":[{"href":"https:\/\/distilinfo.com\/healthplan\/wp-json\/wp\/v2\/posts\/13166"}],"collection":[{"href":"https:\/\/distilinfo.com\/healthplan\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/distilinfo.com\/healthplan\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/distilinfo.com\/healthplan\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/distilinfo.com\/healthplan\/wp-json\/wp\/v2\/comments?post=13166"}],"version-history":[{"count":4,"href":"https:\/\/distilinfo.com\/healthplan\/wp-json\/wp\/v2\/posts\/13166\/revisions"}],"predecessor-version":[{"id":13170,"href":"https:\/\/distilinfo.com\/healthplan\/wp-json\/wp\/v2\/posts\/13166\/revisions\/13170"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/distilinfo.com\/healthplan\/wp-json\/wp\/v2\/media\/12247"}],"wp:attachment":[{"href":"https:\/\/distilinfo.com\/healthplan\/wp-json\/wp\/v2\/media?parent=13166"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/distilinfo.com\/healthplan\/wp-json\/wp\/v2\/categories?post=13166"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/distilinfo.com\/healthplan\/wp-json\/wp\/v2\/tags?post=13166"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}