Sachin H. Jain: Why a lawsuit over Star ratings is one of the proudest achievements of my career

The other day, I had a conversation with a colleague I've worked with for years. He's familiar with my career, and he was utterly surprised when I told him that one of my proudest achievements is the lawsuit that my company, SCAN, filed against the Centers for Medicare and Medicaid Services (CMS) challenging our Medicare Advantage Star rating. 

Background

Before the 2024 Star ratings were announced in October of last year, SCAN had received 4-Star ratings or higher nine years in a row. Then, in 2023, CMS changed the methodology it used to calculate the ratings, and SCAN dropped from 4.5 Stars to 3.5 Stars. This single-Star drop translated to $250 million in reduced revenues — money that would have gone to providing better benefits to our members and reimbursements to our physician groups. 

We weren't the only plan whose ratings dropped. In 2022, 68% of plans received four or more Stars. But under the new methodology, just 42% of plans received four or more Stars. According to my team's rough estimates, that meant a million MA members across the country would see their benefits reduced. 

The new system seemed arbitrary. Our score was lowered because CMS said we took too long to respond to a "secret shopper" call designed to test our French language interpretation protocols. A single call placed by a secret shopper that seemed designed to confuse our representatives cost our members $250 million. 

In 2023, CMS said it would use a new methodology known as the Tukey Outer Fence Outlier Deletion Method in Star ratings calculations. CMS told plans it was implementing Tukey in 2020, but then left the changes out of its 2022 regulations before inserting it into a 2023 rules preamble. As I told my staff, "They're changing the test on us, but they're not being clear about when the new test will be given."

Frustration and Encouragement

When the 2023 Star ratings were released, the industry collectively shrugged. I called other health plan leaders and they all expressed a similar fatalism: CMS is the government, and the government can do what it wants to do. 

At SCAN, we appealed our ratings five times. But after months of filings and back and forth conversations with regulators, we got nowhere. Which is when we considered a lawsuit. 

If you're a health plan, suing CMS isn't something you decide to do lightly. The SCAN board urged caution. CMS is both our benefactor and our regulator, they reminded me. I’ll admit, there's a lot of wisdom in the idea of not challenging the people you rely on both to fund and regulate your business. 

Risk and Responsibility

We filed the lawsuit in late 2023. Hoping for some safety in numbers, I called colleagues at different plans, urging them to sue. To their credit, the leaders of Elevance, my former employer, which had been dinged for missing a single call they maintain was never received, also filed a lawsuit. And then we all waited. 

Six months later, I was finishing a call on a Monday afternoon when I got the news from SCAN's general counsel. The District Court for the District of Columbia ruled that CMS had violated the Administrative Procedure Act in calculating SCAN's Star ratings. As we had argued, the preamble into which the agency had inserted the Tukey rules was non-binding. A few weeks later, a judge ruled in favor of Elevance. 

As a result of our court victory, CMS recalculated ratings for all MA plans, resulting in $1.4 billion in payments to 60 health plans covering more than a million people. 

A Precedent, Perhaps

A few weeks ago, CMS released its 2025 Star ratings.  

And then, on Sept. 30, UnitedHealthcare filed a lawsuit claiming CMS downgraded its rating based on a secret shopper call that had never connected.  

A few days later, HMO Louisiana, a subsidiary of Blue Cross Blue Shield of Louisiana, filed its own suit, arguing that CMS used "arbitrary and unlawful" methods to calculate its Star ratings.  

And a few days after that, Humana went to court, citing SCAN's successful suit and asking a judge to "retract and recalculate" its Star ratings. 

I have no idea whether these suits have merit. What I do know is that because of a risk my team took — because we stood up for what we believed was right — because we used our court system to challenge a large federal agency that many people consider unchallengeable — because we couldn't let our members miss out on benefits we believe they were promised — a million more Americans will get better healthcare next year. 

No matter what happens next, that's something I'll always be proud of. 

Subscribe to the following topics: 1 medicare advantage star rating2. scan3. centers for medicare and medicaid services (cms)4. lawsuit5. methodology6. benefits7. health plan8. court victory

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