CMS Proposes Medicare Advantage Star Ratings Overhaul, Amid Legal and Operational Updates
The Centers for Medicare and Medicaid Services (CMS) has proposed significant changes to the Medicare Advantage (MA) Star Ratings program, aiming to eliminate about a dozen measures that primarily focus on operational performance and administrative processes.
This move is part of a broader draft regulation that also seeks public input on revising risk adjustment methodologies and other Medicare Advantage policies, including modifications to the Part D prescription drug program. The proposal is anticipated to provide some regulatory relief for insurers amid ongoing challenges related to prior authorization, marketing oversight, and audits.
Humana has announced plans to appeal a recent District Court ruling against it concerning Medicare Advantage star ratings, signaling continued legal contention around the evaluation framework used for MA plans. The appeal will be heard by the Fifth Circuit Court of Appeals, although specific grounds for the appeal have not been publicly disclosed.
In regulatory compliance news, Mission Hospital in Asheville, North Carolina, has been removed from CMS's immediate jeopardy status following investigations by state health authorities. This marks the third occasion since the hospital's acquisition by HCA Healthcare in 2019 that it was placed under such status due to patient safety concerns.
Strategic partnerships in the healthcare sector are also evolving, with Vanderbilt Health and Encompass Health collaborating to develop a 40-bed inpatient rehabilitation hospital near Nashville, Tennessee, slated to open in 2028. Despite the significance of this joint venture, financial specifics remain undisclosed.
Meanwhile, contractual negotiations between BJC Health System and Aetna have stalled, potentially affecting coverage for employer-sponsored commercial plans in the St. Louis area starting January 1. This impasse highlights ongoing challenges in payer-provider contract discussions that can disrupt network access for patients.
Additional health industry developments include significant philanthropic grants aimed at advancing cancer research, such as a $20 million award to Dana-Farber Cancer Institute funded by the foundation of a Facebook cofounder and a $5.5 million anonymous donation supporting pediatric brain tumor research at the Kennedy Krieger Institute. These investments underscore the crucial role of private funding in supplementing research and improving patient outcomes.
Lastly, industry reports indicate that physician practices are encountering 'downcoding' issues with major insurers like Aetna and Cigna, a trend linked to artificial intelligence and private equity influences on claims processing and reimbursement. This development raises important questions about the financial viability of smaller practices and the broader implications of technology-driven claims adjudication in healthcare.