Actionable Insights: Elevance's Successful Star Rating Appeal Strategy
You may have seen that Elevance challenged their star rating for 2024 (applicable to 2025 bids) and won an administrative review that increased their Star Ratings for four contracts, worth an estimated $190 million. Link in the comments.
I just wanted to share this for awareness. From Elevance’s lawsuit (I have not confirmed any of this information):
- Contradictory Interpretation of 7-1-1 Service: CMS considered 7-1-1 operators as agents of the plan, although this is a federally mandated public TTY service and the plan has no control over those operators.
- Disputed Call Attribution: CMS would consider an attempted call via the TTY service 7-1-1 as a 'missed call', even if the call never reached their system due to a technical error not within their control.
- Unattainable Cut Point: CMS set a 5-Star cut point for measure D01 at a 99% success rate, which cannot be achieved with certain sample sizes used (61, 62, 63, or 64 calls) as only a perfect score would equate to a 5-Star rating.
When asked to clarify [the reason for the rating adjustment], a CMS spokesperson said MA plans “may request an administrative review of their ratings” and after the review is completed, “Star Ratings are updated as needed.”
I would recommend looking over these items internally, and reaching out to CMS directly for an administrative review if you believe these issues could have affected your star ratings. Between these two call center measures, the quality improvement scores and the reward factor, this potential issue could have a meaningful impact to your Star Ratings and 2025 revenue!
#HealthcareIndustry #StarRatings #medicareadvantage
