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The Centers for Medicare and Medicaid Services (CMS) has filed an appeal over a decision by UnitedHealthcare to lower its Medicare Advantage star ratings due to a secret shopper phone call. In November 2024, CMS ruled the use of this call in determining UnitedHealthcare’s score, which led to a 5-star rating being reduced to 4 stars. Now, CMS is challenging that ruling in federal court on Tuesday (November 27, 2024).
UnitedHealthcare argued the phone call was the basis for the lower rating, causing significant financial losses and impact on member sign-ups. The case initially went to a court hearing where CMS ruled it unlawful, but no explanation was provided by CMS for its appeal.
This decision is critical as millions of dollars in bonus payments are at stake for insurance plans losing a star rating. A 4-star rating instead of 5 stars could harm financial stability and member growth for providers like UnitedHealthcare.
Other insurers have also sued CMS, including Eivalence, Centene, and Humana, over similar issues with star rating calculations and the role of secret shopper calls in determining scores. The broader legal trend highlights growing concerns over transparency in how these ratings are calculated, potentially affecting millions of consumers.
Source: https://www.healthcarefinancenews.com/news/cms-appeals-unitedhealthcares-star-ratings-win