Centene is taking the federal government to court over the scoring of next year’s star ratings, as the latest major insurer to cry foul over the results.
Centene argued that a secret shopper call from an anonymous surveyor was miscategorized and was held against the insurer when the call’s failure is the fault of the Centers for Medicare & Medicaid Services.
“CMS has decided to hold a single call against [the] plaintiffs, despite the fact that the call never reached [the] plaintiffs’ call center, and there was no call failure due to [the] the plaintiffs,” the lawsuit said. “Rather, the CMS secret shopper’s own call notes show that the shopper’s ‘chat window closed unexpectedly,’ which is a clear failure of CMS’ software.”
If even one phone call conducted by CMS is not successful, a five star rating is impossible. And even one unsuccessful call can negatively impact health plans’ finances because the metric is heavily weighted. Centene estimates the phone call will cost them $73 million in gross revenue.
Seven Centene plans received lower overall star ratings scores and four contracts received a lower Part D summary star rating. Some Centene plans did not receive at least three stars, making those contracts ineligible for providing value-based insurance design benefits. Centene’s average star rating dipped from 3.89 in 2022 to 3.15 next year and had the most contracts scoring 2.5 stars or worse among major competitors.
Other insurers have slammed CMS with lawsuits, claiming the feds unfairly scored them due to unsatisfactory customer service and secret shopper calls when the insurers were not at fault.
UnitedHealth and Humana initiated new lawsuits over 2025 star ratings this month, likely encouraged by legal success from SCAN Health Plan and Elevance Health over 2024 star ratings. CMS then recalculated its quality ratings. UnitedHealth also put the onus on one phone call, while Humana said three phone calls were scored unfairly.
It’s a contentious issue for health plans that rely on strong star ratings results to obtain funds, as well as attract and retain beneficiaries. CMS attempts to ensure the highest echelon of star ratings is hard to achieve to incentivize insurers in pushing for better health outcomes.
Centene has more than 28 million members across all lines of business. The lawsuit was filed in the U.S. District Court for the Eastern District of Missouri.