The CMS star ratings challenge
Annually, the Centers for Medicare & Medicaid Services (CMS) releases star ratings, which measure the quality of care health plans deliver for its members. Launched in 2007, star ratings enable CMS and consumers to compare health plans on metrics beyond cost. Today, however, the CMS Five-Star Quality Rating System allows consumers to compare health plans based not only on premium costs but also on a payer’s performance, network, and beneficiary reviews.
Star ratings combine and average the scores reported for individual health plan components of each plan (e.g., Medicare Advantage and Part D); as a result, they provide a comprehensive assessment of a health plan’s performance. CMS awards 5-star ratings to health plans that deliver the highest quality of care and achieve exceptional member satisfaction.
(Note: There are 46 quality and performance measures used for rating by the CMS.)
Each year, the CMS develops cut points—based on the performance of all plans for each measure over the previous year—which means that maintaining the same level of performance year after year is not enough to sustain a high star rating. Therefore, as health plans improve their quality, it becomes increasingly difficult to move from four to five stars. This is because the distribution of scores shifts upward in parallel, making it harder for any plan to stand out.
Why are CMS star ratings important?
The Affordable Care Act of 2010 mandates that CMS make quality bonus payments (QBPs) to Medicare Advantage (MA) organizations that achieve at least four stars in a 5-star quality rating system. Additionally, starting in 2012, CMS incentivizes health plans to improve member experiences by increasing the QBP amount based on their star rating.1 The goal is to ensure health plans commit to improving their performance as it relates to disease management, preventive care and customer service. The higher the ratings, the larger the bonus payments health plans receive from the government. With billions of dollars at stake for payers with CMS star ratings above 3.5, health plans want to earn four stars or higher as quickly as possible.
New CMS star ratings criteria 2021
Although CMS did not introduce new measures, it increased the weight of member experience, complaints, and access measures from 1.5 to 2. This change affirms CMS’s commitment to serving Medicare beneficiaries by prioritizing patients, including their assessments of the care received. Furthermore, CMS also eliminated the requirement for health plans to submit Healthcare Effectiveness Data and Information Set (HEDIS) and Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey data.
With the CMS release of the Final Rule for Contract Year 2021 on May 22, 2020, Medicare Advantage (MA) plans gained near-term clarity regarding the many star-rating proposals made earlier this year. However, achieving or sustaining strong star ratings—especially with the increased weight of the CAHPS and administrative measures—will push health plans to adopt more proactive and nuanced activities than they typically perform.
The CMS Star Ratings Plan Preview periods are now active and—like so much of life in 2020—everything will be unique. Given the dynamic nature of the Medicare Advantage environment and of healthcare policy, insurers and other stakeholders must keep a watchful eye on several industry trends.
Read More –Â Medicare Star Ratings Changes 2021Â
Industry trends
In the highly regulated healthcare insurance industry, health plans handle thousands of appeals and grievances each year. For example, a member may request the plan to reconsider a decision, or a provider might dispute how the plan processed a claim.
Combined, these appeals and grievances can cost health plans millions of dollars each year. And, with more individuals projected to obtain healthcare insurance within the next few years, this means that health plans can expect a proportionate increase in A&G cases, as well.
With changing regulations, complexities are also likely to increase. Mismanaging appeals and grievances can result in severe penalties, such as lower Medicare star ratings on the moderate side, or the cancellation of contracts and licenses at the extreme end of the spectrum.
The CMS continually updates the performance levels required for ratings and, over the past several years, the trend shows it’s getting harder for healthcare payers to achieve four stars. So it should come as no surprise that it’s even harder to achieve a five-star rating; in 2019, only 21 plans received a five-star rating whereas 24 healthcare payers received the top rating in 2018.3
Given these trends, health plans must act now to improve their grievances and appeals processes to help achieve higher star rating. And Inovaare’s Appeals & Grievances solution empowers them to do just that through cloud-based automation.
A&G automation with single-click compliance
Digital transformation is no longer an option. It’s a necessity for every health plan.
To stay nimble within a rapidly changing regulatory environment, payers must carefully assess and deploy the automation technologies needed to meet their unique A&G business challenges. But this much is certain: Digitization can reduce costs, decrease penalties, optimize workflows and improve productivity, all of which will boost a payer’s star ratings.
How it works
Inovaare’s Appeals and Grievances solution empowers operations teams through real-time data visibility that supports accurate monitoring, better decision making and expedited resolutions of all A&G cases. Whether a case is submitted via mail, email, fax, a web portal, member services or even on paper forms, all information gets integrated into Inovaare’ s A&G system in real time so compliant reports can be submitted with click of a button.
Seamless integration with core claims, utilization management and other transaction systems grants flexibility and scalability to all processes related to appeals and grievances. This intelligent system notifies A&G specialists of duplicate cases instantly and it also prevents fraudulent cases from being processed, which saves valuable time and resources.
Inovaare’s solution empowers compliance and A&G teams to collaboratively scrutinize and validate claims and authorization—as well as all pertinent member and provider information—within a unified interface. This makes in-depth investigation quick and easy for every user.
Acknowledgement, extension letter and determination letters are automatically generated, using pre-populated formats to ensure continuous compliance. Inovaare’s A&G solution also automatically calculates turnaround time for resolution of cases and then generates a due date, making the entire process more compliance driven.
Improved member experience is your reward
A positive customer experience is a key to business growth and plays a critical role in achieving high star ratings. Ideally preventing or, at a minimum, mitigating and resolving issues faster while ensuring consistency across all processes are critical to keep the customer happy. Inovaare’s comprehensive A&G solution with the optional Complaint Tracking Module allows health plans to track all cases at each stage of the process to ensure timeliness without compromising compliance.
If you haven’t yet, it’s time to break down silos throughout your health plan and facilitate real-time collaboration across all departments. Inovaare’s A&G software optimizes your processes so you can handle large volumes of data, reduce costs and ensure transparency to prevent fraud at every step. Take a bold and innovative approach to digitally transform the way your health plan manages appeals and grievances and watch your star ratings … and revenue … rise. Appeals and Grievances
Craig Giangregorio, A&G Industry Expert
References
- Centers for Medicare & Medicaid. 2012 Quality Bonus Payment Distributions and
Administrative Review Process for Quality Bonus Payments and Rebate Retention
Allowances. CMS. December 2010. - Centers for Medicare & Medicaid. Year 2021 Medicare Advantage and Part D Final
Rule (CMS-4190-F1) Fact Sheet.
CMS Newsroom. May 2020. - Centers for Medicare & Medicaid. Medicare provides continued access to high-quality
health coverage choices in 2019.
CMS Newsroom. October 2018.