{"id":14206,"date":"2025-04-21T12:49:10","date_gmt":"2025-04-21T12:49:10","guid":{"rendered":"https:\/\/distilinfo.com\/healthplan\/?p=14206"},"modified":"2025-04-21T12:49:10","modified_gmt":"2025-04-21T12:49:10","slug":"cms-rejects-humanas-medicare","status":"publish","type":"post","link":"https:\/\/distilinfo.com\/healthplan\/cms-rejects-humanas-medicare\/","title":{"rendered":"CMS Rejects Humana’s Medicare Rating Appeal"},"content":{"rendered":"
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Insurer Faces Significant Financial Impact<\/h2>\n

Humana, one of America’s largest Medicare Advantage organizations, has reached a critical juncture in its ongoing dispute with the Centers for Medicare & Medicaid Services (CMS). According to a recent court filing, CMS has rejected Humana’s administrative appeal regarding its star rating quality bonus payment scores. This decision will become “final and binding” by April 28, with a CMS officer having until that date to potentially modify the denial notice.<\/p>\n

Legal Battle Over “Arbitrary” Methodology<\/h2>\n

The rejection comes amid Humana’s lawsuit against CMS, filed alongside the nonprofit trade association Americans for Beneficiary Choice. In its legal challenge, Humana contends that the federal government’s actions violate the Administrative Procedure Act, characterizing them as “arbitrary” and detrimental to beneficiaries.<\/p>\n

Humana has now informed the court of this rejection in response to CMS’s previous motion to dismiss the lawsuit. The federal agency had argued that dismissal was appropriate because Humana had not yet completed the administrative claims process.<\/p>\n

Appeal Process Deemed Futile<\/h2>\n

According to Humana’s court documents, pursuing an administrative appeal was never going to yield positive results. The insurer’s fundamental argument centers not on calculation errors but on the fairness of CMS’s methodology itself. Additionally, Humana claims that an “unconstitutionally-delegated contractor” implements the CMS regulations and methodology that determine these critical ratings.<\/p>\n

Given these circumstances, Humana is now requesting an expedited judgment from the court.<\/p>\n

Beyond Technical Disagreements<\/h2>\n

“The data and calculations underlying the annual star ratings are dizzyingly complex, and at a first glance, this suit may appear to be a dry disagreement over technical details,” the health plan stated in court documents. “It is anything but.”<\/p>\n

Humana’s legal argument extends beyond mere calculations. The insurer alleges that CMS has failed to follow its own regulations by:<\/p>\n