Humana ‘Moved the Goalposts’ in Medicare Payment Suit, DOJ Says

Medicare Advantage insurer Humana Inc. has “moved the goalposts” and should be denied a motion seeking additional records in its lawsuit challenging the Biden administration’s calculation of the insurer’s quality measure, or “star rating,” the Department of Justice says.

After Humana claimed that the Centers for Medicare & Medicaid Services failed to produce administrative records in the case, the agency provided additional material. But Humana claimed that the additional data was insufficient to allow for summary judgment briefing on one of the counts in its lawsuit filed in US District Court for the Northern District of Texas.

On Nov. 27, Humana “moved the goalposts” by filing a motion requesting a complete administrative record, and another motion to amend its original lawsuit, the DOJ asserts. “Yet their Amended Complaint—which the Motion to Complete cites throughout—substantively modified the scope of Count I,” in the original lawsuit, the DOJ claims in its Dec. 6 response to Humana’s filing of the two motions.

“CMS compiled and filed a complete Administrative Record consistent with the original complaint. Plaintiffs have not, and cannot, make the legally required significant showing that the Administrative Record is incomplete,” the DOJ filing said. Humana “moved the goalposts and now accuse Defendants of missing a field goal. Their motion should be denied,” the DOJ filing said.

Humana sued the CMS to contest its 2025 “star ratings,” which determine how much it will receive in 2026 from the Medicare Advantage Quality Bonus Payment program. The complaint involves disputed encounters between CMS test callers and the insurer’s call center staff. Humana claims that the CMS wrongly downgraded its quality scores and star ratings as a result of the encounters.

In a similar suit by UnitedHealthcare, Judge Jeremy Kernodle of the US District Court for the Eastern District of Texas ordered the CMS to re-calculate UnitedHealth Group’s 2025 star ratings, finding the agency “acted contrary to its own guidelines” in determining that a CMS test caller didn’t “connect” with the insurers’ telephone call center team.

A similar suit by Centene is also pending. Centene claims it will lose an estimated $73 million due to the lower ratings. It also has asked that the CMS recalculate its quality scores and ratings.

This year, Medicare Advantage plans are expected to receive $15 billion in bonus payments from the Medicare Quality Bonus Program, according to the Medicare Payment Advisory Commission.

These recent complaints follow the template of successful lawsuits by SCAN Health and Elevance Health Inc.

The SCAN and Elevance suits claimed the CMS erred in calculating their star ratings, violated the Administrative Procedure Act, and wrongly penalized the insurers for similarly disputed call center episodes.

In June, the CMS notified all Medicare Advantage plans that it would recalculate their 2024 star ratings based on the SCAN and Elevance challenges.

The case is Humana v. HHS, N.D. Tex., No. 4:24-cv-01004, response 12/6/24.