Medicare Advantage plans face mounting pressure to improve Star ratings. The key to unlocking higher scores? Clean, complete, and current provider data.
The pressure on Medicare Advantage (MA) plans to improve CMS Star ratings is higher than ever—and the cost of falling short is real. For small and mid-sized plans, a half-star drop can mean millions in lost revenue, reduced benefits, and declining member trust. In a Leap Orbit Interoperability Roundtable, Leap Orbit co-founder David Finney and Barry Volin, CEO of the Managed Care Resource Alliance (MCRA), explored a timely but often overlooked connection: how poor provider data quality can undermine member experience and ultimately damage Star performance.
This conversation sheds light on the root causes of member dissatisfaction and the ripple effects of inaccurate provider directories—and calls on health plan leaders to treat provider data not as a back-office issue, but as a frontline driver of member loyalty and financial performance.
In the past, Medicare Advantage Star ratings heavily relied on transactional metrics like whether members completed annual physicals or received post-discharge follow-up. But in recent years, CMS has shifted its focus toward member experience as a core performance indicator. In 2024, over 50% of the Star rating formula is based on member experience measures, primarily sourced from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey.
This isn’t an incremental change—it’s a complete rebalancing of priorities. As Volin noted, “Absent that revenue [from Star-related bonuses], plans can’t offer supplemental benefits like dental or vision. Staying competitive requires maintaining or improving those scores.”
CAHPS surveys ask members to rate their ease of getting care, satisfaction with provider choice, and ability to get timely appointments. These might seem like operational or access issues—but as Finney argues, they are fundamentally data issues.
“If you're falling down on the accuracy and actionability of your provider data, you're falling down on CAHPS,” Finney said. Inaccurate directories lead to failed appointments, out-of-network charges, and lost trust at the moment of care—all of which get reflected in CAHPS scores.
This theory isn't just speculative. A 2023 review from the Journal of the American Medical Association found that provider directory inaccuracies were among the top five complaints reported by Medicare beneficiaries about their plans’ services (JAMA Health Forum, 2023). A 2022 HHS audit also revealed that nearly half of provider directory locations listed were inaccurate, inaccessible, or both.
Volin, who spent 35 years in managed care leadership, recently experienced these problems firsthand as a Medicare Advantage member. After moving to Florida, he struggled to find accurate information about providers’ network status, hospital affiliations, and availability—even when using plan-approved directories.
“I literally threw up my hands,” he said. “If the data they’re providing to me to make my initial decisions is not correct, then what’s my level of confidence in anything else they provide?”
The disconnect between plan expectations and member experience couldn’t be starker. “My pickleball partners,” he joked, “spend more time researching sneakers on Amazon than we can spend figuring out where to get our healthcare.”
Traditionally, provider directories were viewed as a compliance deliverable, updated infrequently and managed by siloed teams. But that approach no longer holds up under current expectations. Members expect Amazon-like transparency and usability. CMS is demanding continuous improvement. And Star rating formulas now reward plans that meet both.
Still, many health plans respond to poor CAHPS results by retraining call center staff or revamping appeals and grievances processes—reactive measures that, while important, don’t solve upstream data issues.
Volin emphasized, “The real question is: Are we just throwing old solutions at new problems?”
Improving provider data accuracy is not just about fixing records—it’s about enabling a better member experience from day one. As Volin outlined, the two most critical things a new member needs when joining a plan are:
Without these, the entire member journey starts on shaky ground. And when members can’t find in-network providers or receive surprise bills due to faulty information, trust is eroded—and retention suffers.
Research supports this. A 2022 JD Power study on Medicare Advantage member satisfaction ranked provider access and digital tools as top drivers of loyalty, ahead of cost factors. And according to CMS data, plans that consistently maintain 4 or more stars see higher enrollment growth and lower member churn.
One of the key insights from the discussion is that poor provider data quality is often a systemic issue obscured by internal silos. Provider network management, call centers, compliance, and IT often operate in isolation, tackling the same problem from different angles without a unified strategy.
Volin urged leaders to elevate provider data to an enterprise-level concern: “We need to get the provider, the health plan, and the member on the same side of the table—all negotiating around the desired clinical outcome, including satisfaction.”
Convergent, Leap Orbit’s provider data automation platform, was briefly mentioned as a tool for transforming qualitative member experience issues into measurable, trackable metrics. These metrics can include:
These aren’t just technical metrics—they’re business metrics. Finney noted that small health plans with just 100,000 members stand to lose over $15 million annually from a half-star drop in CMS ratings. “That’s not just lost revenue,” Volin added. “That’s the money you need to fund supplemental benefits that keep your plan competitive.”
To compete in today’s Medicare Advantage market, plans must view provider data as the front line of member experience. That means making it easy for members to:
It also means empowering internal teams with the right tools to maintain that data without wasting hours on manual entry or back-and-forth phone calls.
The final takeaway? Member perception is reality. And in a world where CAHPS now governs over half of a plan’s Star score, perception starts with provider data.
To stay competitive in the CMS Star-driven environment, health plans should consider:
In a market where consumers are demanding more and regulators are demanding better, plans that get provider data right will be best positioned to deliver both.