Comment on CMS 4212-PHonorable Mehmet Oz, MD, MBA Re: 2027 Medicare Advantage (MA) proposed rule (CMS-4212-P) January 12, 2025Dear Administrator Oz: On behalf of the American College of Physician Advisors (ACPA), we submit comments on the Contract Year 2027 Medicare Advantage (MA) proposed rule (CMS-4212-P), with specific focus on CMS’s proposal to remove two interrelated policy areas in the proposed rule: beneficiary complaint measures and the “Reviewing Appeals Decisions” metric within the MA Star Ratings program. Physician advisors work at the intersection of utilization management, real-time clinical decision-making, and care coordination. Through daily interaction with Medicare Advantage organizations, physician advisors have direct insight into how MA plan operational practices affect beneficiary access to medically necessary care. As MA enrollment continues to grow, Star Ratings remain a central mechanism through which CMS promotes accountability, beneficiary protections, and program integrity. We appreciate CMS’s continued efforts to refine Star Ratings to ensure they reflect meaningful and reliable indicators of plan performance. Relevant Proposed Rule DiscussionCMS proposes removing certain complaint-related measures from MA Star Ratings, including Plan Makes Timely Decisions about Appeals and Reviewing Appeals Decisions (CMS-4212-P, Section II.F). CMS expresses concern that complaint measures may not consistently reflect clinical quality and may be better suited for monitoring or enforcement. While ACPA supports CMS’s goal of maintaining clinically meaningful quality measures, we strongly urge CMS to retain beneficiary complaint measures and the “Reviewing Appeals Decisions” metric within the Star Ratings framework. Why Beneficiary Complaints and Appeals Measures Remain Essential to Star RatingsFrom a physician advisor's perspective, beneficiary complaints and appeal-related measures are critical indicators of MA plan performance that are not fully captured by clinical quality or administrative process measures. Complaints and appeals measures commonly arise in connection with:
These issues reflect systemic utilization management and appeal practices that interfere with timely access to medically necessary care and undermine beneficiary protections that are foundational to the Medicare Advantage program as established under 42 C.F.R. Part 422. Complaints and appeals measures, therefore, serve as an important proxy for how coverage and Medicare Advantage Member Benefits function in practice. Complaints and Appeals Metrics as Behavioral and Accountability SignalsBeneficiary complaints are not merely expressions of dissatisfaction but are actionable signals of restrictive or inappropriate coverage determinations. Including complaint measures in Star Ratings reinforces accountability for how MA plans operationalize access, coverage, and appeals requirements, complementing clinical quality metrics with real-world beneficiary experience. Critically, the direct financial impact of Star Ratings is a key driver of MA plan behavior. When complaint-related measures affect Star Ratings, plans have a tangible incentive to improve appeals processing, reduce inappropriate denials, and address operational barriers to timely care. Removing these measures would weaken accountability and reduce incentives for plans to address beneficiary concerns, even where those concerns implicate compliance with existing Part C requirements. Plan Behavior Observed Under the Reviewing Appeals Decisions MetricACPA members observed that, in 2024, many MA organizations sought to protect performance on the Reviewing Appeals Decisions metric through one of two approaches. Some plans appropriately overturned denials upon appeal. More commonly, however, plans incorrectly asserted that certain inpatient admission or level-of-care denials were not appealable by beneficiaries and therefore declined to process those appeals. This practice shielded plans from Star Ratings impact while denying beneficiaries access to required appeal protections. CMS Recognition of Misapplied Appeal RightsCMS has acknowledged that these aforementioned plan practices reflect widespread misapplication of Medicare Advantage appeal regulations rather than isolated compliance failures. In CMS-4208-F, CMS explicitly recognized that many MA organizations were improperly denying enrollees access to appeal rights for adverse concurrent review decisions, including inpatient admission and level-of-care denials. CMS stated: “Commenters are correct in their understanding… As explained, we proposed the modification to §422.562(c)(2) in order to eliminate potential confusion and create uniformity across the MA program, as we understood many MA organizations have been misapplying the regulation and improperly denying enrollees appeal access for adverse coverage decisions.” CMS concluded that the inconsistent and widespread misapplication of concurrent review and appeal policies resulted in direct and significant harm to beneficiaries: “The direct consequence of the misapplication of MA policies is that many enrollees do not receive notice of a decision to downgrade their level of care from inpatient to outpatient, nor are they given opportunity to appeal.” Retaining and refining complaint and appeals measures more closely aligns plan incentives with CMS’s stated priorities of access, transparency, and beneficiary protection. RecommendationsACPA recommends that CMS:
ConclusionRemoving beneficiary complaint measures and the “Reviewing Appeals Decision” metric from Medicare Advantage Star Ratings would weaken a key accountability mechanism at a time when beneficiary access, transparency, and protections remain central CMS priorities. Retaining and refining these measures will better align Star Ratings with real-world beneficiary experience, reinforce compliance with existing Medicare Advantage requirements, and strengthen Medicare Advantage program integrity. Sincerely, Ahmed Abuabdou, MBBS, MBA, ACPA-C |