UnitedHealth Sues US Over Quality Rating Drop Tied to Phone Call

Affiliates of one of the nation’s largest Medicare Advantage plans sued the Biden administration claiming that their quality rating was unreasonably downgraded after one customer service phone call.

The complaint filed Monday by subsidiaries of insurance giant UnitedHealth Group Inc. alleges the Centers for Medicare & Medicaid Services downgraded the company’s “Star Ratings” based on an “arbitrary and capricious assessment of how Plaintiffs’ call center handled a single phone call that lasted less than ten minutes.”

The plaintiffs asked the court to act urgently with an injunction to correct the CMS rating, as open enrollment is set to begin Oct. 15.

Star ratings, which range from one to five stars, play a crucial role for Medicare Advantage insurers. Higher ratings allow plans to receive bonuses and enroll more members, while poor ratings can lead to terminated contracts and an inability to market to new customers.

The plaintiffs claim a CMS test caller had connected to one of UnitedHealth’s representatives, yet at no point during the eight-minute phone call “did the CMS test caller ask the required introductory question.” For this reason, the lawsuit claims, “the customer service representative did not have the opportunity to provide a response” and the company was unfairly docked on their quality rating score.

Although the lawsuit claims “the CMS has a practice of invalidating calls, among other reasons, when there is no evidence that the plan was at fault for a call that was not successfully connected or completed,” the plaintiffs assert the agency “made its final decision” without addressing any of the arguments raised by UnitedHealth.

Unless corrected by the court, the insurers say the decision to downgrade the companies’ quality rating will “misinform millions of current and potential customers, deterring them from choosing Plaintiffs’ plans as their insurers for 2025.”

The plaintiffs seek an injunction by the court requiring the CMS to recalculate their Star Ratings without considering the disputed call.

Alston & Bird LLP represents the insurance companies.

The case is UnitedHealthcare Benefits of Texas v. CMS, E.D. Tex., No. 6:24-cv-00357, complaint 9/30/24.