Star rating victories
Over the last year, we’ve seen victories in Centers for Medicare and Medicaid services (CMS) rulings, including a recent landmark victory in November. This marks a pivotal moment for the healthcare sector, particularly in the Medicare Advantage space. The November ruling, which required CMS to recalculate the massive health insurance plan’s 2025 star ratings, signals a significant shift in how quality metrics are evaluated and managed in the healthcare industry.
The recent ruling follows a pattern of successful legal challenges against CMS's star ratings methodology. In a similar case last year, Elevance Health achieved a significant victory that led to CMS recalculating star ratings for all Medicare Advantage plans in July 2024, resulting in $1.4 billion in payments to 60 health plans, covering more than a million people. The trend continues with Centene's pending lawsuit, where they claim that the inclusion of a single customer service call could potentially cost them $73 million in bonus payments. These cases highlight the substantial financial implications of star ratings and the industry's growing scrutiny of CMS's evaluation methods.
With Medicare Advantage star ratings directly impacting everything from bonus payments to consumer choice during enrollment periods, healthcare payers are increasingly focused on maintaining and improving their ratings through innovative solutions.
Innovation door opener
This development comes at a crucial time when the industry has seen a dramatic decline in top-performing plans. The number of 5-star plans dropped from 38 in 2024 to just 7 in 2025, highlighting the growing challenges healthcare payers face in meeting and exceeding quality standards that are becoming increasingly stringent.
However, this challenge also presents an opportunity for innovation. Leading healthcare organizations are turning to advanced technology solutions to enhance their star ratings performance. For instance, Blue Cross Blue Shield of Michigan has maintained consistently high performance in the CMS Stars program, achieving a 4.5-star rating in 2023 for both their HMO and PPO plans.
Master the basics, watch performance soar
The key to such success lies in implementing comprehensive solutions that address multiple aspects of star ratings improvement:
- Enhanced member experience: Implementing advanced customer service platforms that provide seamless, personalized interactions
- Streamlined operations: Leveraging end-to-end utilization management, integrated with industry-leading guidelines
- Data-driven decision-making: Leveraging analytics to identify and address care gaps proactively
- Regulatory compliance: Ensuring timeliness in actions and maintaining HIPAA-compliant data usage
As the healthcare industry continues to evolve, the focus on star ratings will only intensify. Organizations that invest in innovative solutions today will be better positioned to maintain high performance in this increasingly competitive landscape.
Learn more
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