In January, Elevance Health, the 4th largest Medicare Advantage carrier, sued the U.S. Department of Health and Human Services (HHS) and Centers for Medicare & Medicaid Services over $190 million in lost Medicare enrollment bonus payments.  Worse, they anticipate the ultimate revenue impact will reach $500 million.

The lawsuit win means Elevance Health now has four Medicare Advantage (MA) contracts with higher 2024 ratings after CMS updated the original scores announced in October, according to a regulatory filing.

Why Sue?

Elevance Star Rating was impacted by One (1)  TTY  "secret shopper" call during last year's CMS Star Rating testing season and they argue the call never came in. 

The original star rating reduction and the subsequent lawsuit were based on a single missed call from CMS testers, which caused Elevance to fail its required 99% success rate. Elevance states that the call dropped through no fault of their own.  

In the lawsuit, Elevance argued that the Tukey method  was used as an "unlawful, and arbitrary and capricious" methodology to change star ratings. The insurer argued that Tukey does not consider the 5 percent guardrail for cut points and therefore CMS violated the guardrail regulation when deciding 2024 star ratings. The lawsuit also argues that it would have been impossible to meet that success rate without a 100% call completion (not a single call miss) vs the 99% stated.

Notable Impacts 

Elevance was able to sue HHS and receive new, improved ratings, do other providers have evidence that can support the same argument? Additionally, how will other providers evaluate their TTY service providers and records after Elevance highlights the 'real cost' of star reduction?

 Elevance uses the federally funded (and free) 711 text telephone service. CMS's view (as told by our clients) is if you use 711, you're on your own.  And because you don't have their call data, you have no way of disputing. Elevance got lucky this time because of the statistical calculation, but next time would CMS expect more evidence?

The Right Solution

With NexTalk, you have access to everything and have the data to rebut scoring issues without needing to go to court. Providers who put their fate in a government-funded 711 service, are choosing to save thousands while risking millions.

REAL LIFE CASE

A NexTalk customer, the largest non-profit health insurer in NY, faced this exact scenario--a disputed CMS test call failure. By providing all the call data from our system and our carriers, they proved the failed call didn't happen. CMS overturned the lower score, which raised their aggregate rating above the key 4-Star threshold.

In their own words, this meant tens of millions of dollars...and no court date.

For insurers, who like quality control, who prioritize having the data to back up a claim, and who seek to provide a better experience for this often underserved community ... remember free isn't always free.

And when it comes to TTY - NexTalk is here to help.