text-size: + - R

Rx News

CMS' Star Ratings Presents Challenges and Opportunities

Karen Cassidy, MD

November 18, 2015

Whether you work in a small physician practice or large hospital group, the Centers for Medicare & Medicaid Services Star Ratings and their documentation requirements may feel like a mixed blessing.

On the one hand, Star Ratings help increase the number of Medicare Advantage recipients who complete annual wellness visits and recommended preventive health screenings, which ultimately may improve health outcomes.* But the corresponding documentation requirements can also create an administrative burden for your practice staff.

Because it is a CMS requirement to release information showing care opportunities have been closed, and because closing care opportunities may help improve health outcomes, UnitedHealthcare provides resources and support to help its network care providers close care opportunities and document and submit this information for our members.

CMS uses Star Ratings to evaluate health plan quality for Part C Medicare Advantage and Part D Prescription Drug plans. Star Ratings are reported on a scale of one to five stars, with five being the highest quality score. Star Ratings give consumers information to help them compare the performance of Medicare Advantage plans. Medicare Advantage health plan overall Star Ratings determine the level of quality bonus payments earned from CMS. The ratings are published on medicare.gov every October.

CMS calculates Star Ratings based on quality measures that reflect care opportunities using the following five main data sources:

  • Claims and medical record chart data: The National Committee on Quality Assurance's Healthcare Effectiveness Data and Information Set
  • Member survey focusing on service experience and access to care: Consumer Assessment of Healthcare Providers and Systems
  • Member survey focusing on members' perception of health status: Health Outcomes Survey
  • Pharmacy measures: Prescription Drug Event
  • Member complaints, appeals and grievances (from health plan operations)

To calculate Star Ratings, CMS requires medical practices to submit documentation showing care opportunities have been closed, and targeted measures have been met for their patients.

To that end, UnitedHealthcare collaborates with its network care providers by offering programs, tools and resources to help with their efforts in identifying and closing care opportunities for eligible patients-and then documenting and submitting this information to show the opportunities have been closed. (Patients do not need to sign a release to allow physicians to submit the patient-specific information required to comply with CMS quality reporting guidelines.) Some of the following programs, tools and resources are not available to all providers or members.

We encourage you to take advantage of all of the resources available to you to help close care opportunities for your patients,including those from the health insurance companies you work with. Here are some of the programs we offer UnitedHealthcare network providers:


PATH gives our network providers tools and support to help encourage patients to become more engaged with their preventive health care - and provides opportunities to earn additional compensation, if eligible, for exceeding quality-based performance targets. And because we understand it takes extra time to review and complete assessment forms, we offer additional compensation to recognize these administrative efforts.

The PATH program provides several kinds of financial compensation:

  • Healthcare Quality Patient Assessment Form (HQPAF) Payment
    Eligible network care providers can earn competitive payments for completing an HQPAF for each qualifying patient.
  • PATH Bonus Programs
    By improving specific HEDIS measures for eligible UnitedHealthcare Medicare Advantage members, network care providers may earn annual bonus payments.
  • Annual Care Visit and Member with Diabetes Bonuses
    For 2015, some PATH programs offer additional bonus payments for getting UnitedHealthcare Medicare Advantage members in for an annual care visit and an even greater bonus when members with diabetes come in for an annual visit. Bonus amounts depend on when the visit is completed and achieving the minimum number of member visits within the period.

Care Management and Data Capture Application

UnitedHealthcare offers a care management application referred to as UHCTransitions that gives practices a convenient way to access open care opportunities for their members and submit required closure documentation that meets CMS requirements. It also identifies members who have preventive care opportunities. The information is updated daily. After the care opportunities are closed, providers can extract the required documentation directly from their electronic medical record system and submit it to us using the care management application.

Practice-Based Support

Practice-based support coordinates with PATH programs to support selected practices as they care for our members by offering to:

  • Review charts and electronic medical records to identify care opportunities.
  • Assist your team in scheduling annual exams, preventive health screenings, services, labs and specialist visits as appropriate.
  • Provide support and training for the care management and data capture application, which can help reduce your administrative burden by accessing your electronic medical records system and charts to collect care opportunity information that provides the documentation needed to support the closure of HEDIS care opportunities.

Patient Care Opportunity Reports

Care providers receive actionable patient data in their monthly Patient Care Opportunity Report, which highlights open care opportunities for UnitedHealthcare Medicare Advantage members. It also provides practice-level data that shows the progress practices are making in helping to close those care opportunities. This information is updated daily in our care management application.

HouseCalls In-Home Visits

HouseCalls provides eligible Medicare Advantage members with an annual in-home clinical visit at no additional cost from our trained team of licensed clinicians. The HouseCalls visit includes a health evaluation; review of medical history, medications and diagnoses and education specific to the member's conditions. It also may include lab draws and flu vaccines where available and accepted. After the visit, the HouseCalls practitioner gives the patient a list of suggested topics to discuss with theirprimary care physician and we mail a copy of the results of the HouseCall visit to the individual's primary care physician.

Diabetes Navigator

This program provides case management by telephone to encourage eligible members to comply with their diabetes management and preventive health care programs. This increased disease management and focused treatment aim to help improve A1C levels, reduce admission rates and lower medical costs.

Care Opportunity Patient Assessment Forms

Network physicians who do not participate in our incentive programs and treat UnitedHealthcare Medicare Advantage members with open care opportunities receive a Care Opportunity Patient Assessment Form specific to each eligible patient. These forms highlight open care opportunities for preventive services based on HEDIS performance measures. They also provide a quick way for practices to submit data to us after they have closed care opportunities.

As UnitedHealthcare's Market Medical Director for Tennessee, I encourage you to take advantage of the resources available to you from the health insurance companies you work with. Many have access to claims data that can help you identify patients at the highest risk for having open care opportunities- and potential health complications. These are the same patients who may benefit the most from collaborative outreach.

For more information about how UnitedHealthcare helps its network providers identify and close care opportunities and earn bonus incentives for doing so, contact your local UnitedHealthcare Representative or visit UnitedHealthcareOnline.com. For more information about Star Ratings, visit cms.gov.


News Topics

Tennessee Drug Card

Top News Articles