Centene Corporation has filed a lawsuit against the Centers for Medicare & Medicaid Services (CMS) regarding the scoring of the 2025 star ratings.
The star ratings are crucial for health plans as they affect funding and the ability to attract beneficiaries.
Centene's average star rating has declined significantly, resulting in lower overall scores and some contracts failing to meet the minimum requirement.
The reliance on customer service metrics, particularly secret shopper evaluations, has led to dissatisfaction among insurers.
The financial implications of star ratings extend beyond revenue loss and can affect an insurer's market position.
Centene's lawsuit claims that a miscategorized secret shopper call unfairly impacted their ratings.
The call did not reach Centene's call center due to CMS's software issues, not Centene's fault.
The lawsuit estimates that the misclassified call could cost Centene approximately $73 million in gross revenue.
Other major insurers, including UnitedHealth and Humana, have also filed lawsuits challenging the fairness of the star ratings process.
Insurers are navigating these challenges while advocating for a more equitable ratings system.
The ongoing disputes with CMS highlight the complexities of the healthcare landscape, where regulatory frameworks and market dynamics intersect.
Centene's lawsuit is a strategic move to challenge the validity of the ratings and seek redress for what they perceive as an unjust evaluation process.