Reverse Falling Star Ratings with Next-Generation UM and Intelligent Prior Authorization

For Medicare Advantage (MA) plans, stricter quality thresholds from CMS continue to raise the bar for star ratings, making it harder for plans to achieve high scores. In 2025, the average MA Star Rating dropped from 4.07 in 2024 to 3.92, continuing a three-year downward trend. Additionally, only 40% of MA-PD plans earned four or more stars, a significant decline from 68% in 2022.

These declines are attributed to stricter CMS cut points, rising member expectations, and operational inefficiencies in areas like utilization management and prior authorization. Addressing these challenges is critical for reversing the trend, and advanced solutions like next-generation UM and intelligent PA offer a clear path forward.

Current Challenges with UM and PA

Traditional utilization management and prior authorization processes have long been criticized for creating friction in healthcare delivery:

• Administrative Overload: Manual processes and lengthy approvals add strain to providers, members, and health plans alike.
• Delayed Care: Back-and-forth authorizations can create bottlenecks, unnecessarily delaying access to critical treatments.
• Poor Provider Experience: Cumbersome authorization procedures and lack of transparency can lead to provider dissatisfaction, impacting their ability to deliver timely care.
• Poor Member Experience: Fragmented processes often leave members feeling frustrated, eroding satisfaction—a key factor in Star Ratings.

To effectively move the needle on star ratings, MA plans must do better by addressing these persistent challenges. Next-generation utilization management (UM) and intelligent prior authorization (iPA) solutions offer a path forward by leveraging advanced technologies to streamline processes, reduce administrative burdens, and enhance the overall healthcare experience for both providers and members. These innovative solutions can transform the way healthcare is delivered, ensuring that care is timely, efficient, and centered around the needs of the patient.

Leveraging Advanced UM and PA for Improved Star Ratings

Modern UM and PA solutions harness technology like artificial intelligence (AI), intelligent automation, and predictive analytics to address these challenges while driving measurable improvements in star ratings.

1. Streamlining Prior Authorizations with Automation

Intelligent PA solutions use AI and machine learning to reduce the time and effort associated with manual prior authorizations. These tools can:

• Automate Routine Approvals: For common treatments and low-risk scenarios, approvals can be automated, reducing processing times from days to minutes.
• Identify High-Risk Requests: AI can flag complex cases for further review, ensuring clinical rigor without slowing down routine care delivery.

For example, an MA plan using automated PA saw a 35% reduction in care delays caused by authorization processing, enhancing member experiences and, in turn, improving Consumer Assessment of Healthcare Providers and Systems (CAHPS) scores—key contributors to Star Ratings.

2. Proactively Managing High-Risk Members

Next-generation UM platforms allow MA plans to take a proactive approach by identifying at-risk members earlier. Leveraging advanced analytics, these tools track trends in claims data, health status, and social determinants of health to pinpoint individuals who may benefit from targeted interventions.

• Early Detection: AI-driven analytics can predict future acute episodes, such as hospitalizations, allowing care teams to intervene with preventive measures.
• Personalized Outreach: High-risk members, such as those with chronic conditions, can be enrolled in disease management programs, reducing avoidable complications.

Consider an example where an MA plan used predictive analytics to identify members at risk of hospitalization due to unmanaged diabetes. By intervening with a care coordination program, the plan reduced hospitalizations by 20%, improving the outcomes measures that drive star ratings.

3. Reducing Administrative Burdens for Providers

The provider experience is intricately tied to member satisfaction. Lengthy or inconsistent authorization processes frustrate providers, often leading to delays in care—and member dissatisfaction. Intelligent PA solutions address this by:

• Offering Transparent Workflows: Providers benefit from real-time status updates and clear decision-making criteria for authorizations.
• Reducing Resubmissions: With AI-based checks for common errors in submissions, approvals go through the first time more often.

By improving provider satisfaction and care delivery efficiency, MA plans can score higher on measures related to provider collaboration and care coordination.

4. Enhancing Member Satisfaction and Experience

One of the most tangible benefits of advanced UM and PA is improving the member experience:

• Faster Access to Care: Automated processes mean fewer delays in getting procedures, medications, and referrals approved.
• Seamless Communication: Modern platforms enable updates via text, email, or app notifications, keeping members informed and easing frustration.

For instance, a plan that implemented intelligent PA noticed a surge in positive member feedback, boosting its CAHPS scores on questions related to timeliness of care—a critical metric for star ratings.

Actionable Insights for MA Plan Leaders

To start leveraging next-generation UM and PA solutions for better star ratings, consider these steps:

1. Assess Your Current Gaps: Identify choke points—whether they're in your authorization workflows, member engagement, or provider relationships.
2. Invest in AI-Driven Technology: Look for UM and PA solutions that integrate easily with existing systems while offering robust automation, analytics, and reporting capabilities.
3. Train Care Teams: Proper implementation includes equipping care teams with the knowledge to effectively leverage these tools.
4. Measure and Iterate: Continuously monitor metrics like care delay reductions, provider satisfaction, and CAHPS scores to refine your approach.
   
   

Drive Star Ratings Recovery with Smarter Solutions

Better star ratings are achievable when MA plans leverage technology to meet member needs efficiently and proactively. Next-generation utilization management and intelligent prior authorization are not just tools - they're strategic assets that can help plans drive better outcomes, reduce administrative burdens, and enhance the member experience. By adopting these solutions, MA plans can put themselves on the path to thriving in an increasingly competitive landscape, while delivering the exceptional quality of care their members deserve.