UnitedHealthcare wins lawsuit over star ratings
CMS is ordered to recalculate the star ratings without consideration of a "secret shopper" call that was the focus of the dispute.
Photo: Courtesy UnitedHealth Group
UnitedHealthcare has won its lawsuit against the Centers for Medicare and Medicaid Services over the calculation of Medicare Advantage star ratings.
A federal court in Texas on Friday ordered CMS to recalculate UnitedHealth's 2025 star ratings without consideration of a "secret shopper" call that was the focus of the dispute.
Federal Judge Jeremy Kernodle ruled that CMS's decision to include the disputed call in the 2024 Call Center Monitoring Performance Metrics for Accuracy and Accessibility Study is unlawful. CMS is ordered to recalculate UnitedHealth's 2025 star ratings without consideration of the disputed call and publish the recalculated star ratings in the Medicare Plan Finder.
WHY THIS MATTERS
UnitedHealthcare claimed that its ratings were lowered on the basis of that one phone call. A 4-star rating, rather than a 5-star rating, on this single metric would cause them substantial losses, both financially and in the number of members signing up for plans, according to UnitedHealth.
Plans are rated based on a weighted average of the plan's scores on individual measures, or metrics.
A single, unsuccessful test call prevents a call center from receiving a 5-star rating for the metric. The call center received a 4-star rating based on the call, which reduced the overall star rating for several of UnitedHealth's plans by half a star, according to the complaint.
"The case comes down to a single disputed foreign-language test call," the lawsuit said. "CMS evaluated the call as 'unsuccessful' because, the agency contends, the test caller 'was unable to engage a customer service representative before the call center disconnected the call," according to the decision.
According to court records, a French-speaking test caller dialed the correct number for the call center, used an automated system, and was routed to a French-speaking customer service representative. A voice is heard beginning to say something before being cut off immediately. Fifteen seconds later, the test caller said, "Hello?" in English. Silence followed. The test caller remained on the line until the call center terminated the call after approximately eight minutes.
UnitedHealth challenged the assessment of the call as unsuccessful for several reasons, including relying on a private-party contractor.
CMS requires that interpreters must be available for 80% of incoming calls requiring an interpreter within 8 minutes of reaching a customer services representative.
UnitedHealthcare first objected to CMS's evaluation of the disputed call on July 19. It filed the lawsuit on September 30, prior to the release of the star ratings in October. It asked for a summary judgement on October 15, to correspond with the day annual enrollment began.
On Oct. 30, CMS also moved for a summary judgment. The court held oral arguments on November 18.
THE LARGER TREND
In June, Elevance Health won a lawsuit against the Department of Health and Human Services over star ratings calculations.
Elevance is again suing over this year's star ratings decrease.
It joins Centene, which is also suing over the call measure, saying CMS held a single call that never reached its call center, against the company.
Humana also filed a lawsuit over the calculation of cut points that determine the number of stars.
Email the writer: SMorse@himss.org
