Medicare Star Ratings: 7 Strategies to Improve Performance

Why Star Ratings Matter to Quality and Financial Leaders

Ratings inform member comparisons and quality priorities. Qualifying Medicare Advantage contracts with four stars or higher generally meet the quality bonus payment rating threshold, subject to program rules. Stand-alone Part D contracts do not receive those bonuses. Ratings alone do not establish member suitability.

How CMS Calculates Star Ratings, and Why Improvement Takes Time

Measures Draw on Clinical, Administrative, and Member-Reported Data

HEDIS assesses healthcare performance; not every HEDIS measure enters Star Ratings. CAHPS captures member experience, while the Health Outcomes Survey assesses beneficiary-reported health outcomes. Claims, clinical records, prescription drug events, and administrative data supply other evidence.

Measure Weights and Cut Points Shape Overall Performance

Overall ratings are not simple unweighted averages. Measure weights, performance thresholds—or cut points—and adjustments influence results. Use the applicable CMS technical notes, rather than assuming last year’s methodology still applies.

Measurement Year, Rating Year, and Payment Year Are Different

Care and data collection → submission and validation → rating publication → applicable payment impact

Measurement windows vary; some span multiple years. Map each priority measure’s dates before deciding which interventions can affect a future rating.

Strategy 1 | Prioritize Measures Using Performance, Impact, and Feasibility

Separate Care Gaps From Documentation and Data Gaps

An apparent gap may reflect missing care, missing documentation, incorrect eligibility, an applicable exclusion, or stale records. Validate it first. Retrieving an existing screening result improves evidence completeness—not newly delivered care.

Build a Measure-Level Improvement Portfolio

Evaluate baseline performance, eligible population size, distance from thresholds, measure weight, clinical importance, intervention time, and resource constraints. Balance achievable gains with patient needs; proximity to a cut point should not override clinical priorities.

Strategy 2 | Identify the Right Provider, Location, and Care Team

Validate Identity and Communication Information

Check NPIs, practice locations, affiliations, telephone numbers, and supported secure messaging addresses. An NPI identifies a provider but doesn't indicate which office or communication endpoint handles a request.

Confirm Who Is Responsible for the Next Action

Attribution is not ownership. A member’s attributed primary care provider may differ from the treating specialist or prescribing clinician. Give teams a clear way to dispute assignments and redirect requests without abandoning follow-up.

Maintain Provider Data Across Enterprise Workflows

Document sources, refresh processes, conflicting records, and exception owners across directory, referral, and care management applications. careMESH SEARCH supports provider identification and maintained communication data, helping organizations build a trusted Healthcare Communication Directory.

Strategy 3 | Turn Care Gap Lists Into Actionable Provider Communication

Send Patient-Specific Requests That Explain the Next Step

Replace unexplained spreadsheets with focused requests: the member, identified gap, supporting evidence, requested action, responsible team, and appropriate deadline. Include how recipients can report completed care or correct inaccurate information.

Route Information Into Existing Workflows

Direct Secure Messaging exchanges clinical information securely between organizations. FHIR interfaces, HL7 messages, or document exchange may fit other environments. Confirm where information appears: electronic delivery does not automatically create an actionable EHR task.

Separate Delivery Status From Clinical Completion

Track four distinct stages:

1. Information delivered.

2. Responsibility accepted.

3. Clinical action completed.

4. Valid evidence captured.

careMESH CONNECT supports clinical information delivery. Delivery status alone does not prove clinical completion or measure closure.

Strategy 4 | Strengthen Follow-Up After Care Transitions

Notify the Appropriate Team After Discharge

Send discharge information to the follow-up team, including medication changes, pending results, and next steps. Hospital notification is useful only when someone can translate it into appropriate outreach and clinical review.

Assign Ownership for Follow-Up and Escalation

Designate who contacts the member, arranges appointments, retrieves records, and resolves medication questions. Escalate unreachable members, unavailable appointments, missing records, or disputed responsibility rather than leaving them in an unmonitored queue.

Track Work Against Applicable Measure Specifications

For a member discharged with medication changes, the payer alerts the practice, the practice assigns review, and staff capture evidence. Check current Star Ratings inclusion, eligibility, timing, and documentation requirements before counting any transition-related activity.

Strategy 5 | Address Medication Adherence Through Coordinated Support

Identify the Reason for a Refill Gap

A refill gap may signal cost, side effects, complex instructions, pharmacy access problems, or an intentional treatment change. Ask why before initiating reminders; clinically appropriate discontinuation should not trigger pressure to restart.

Connect Members With Prescribers, Pharmacists, and Care Managers

Prescribers assess treatment concerns; pharmacists clarify dispensing and regimen questions; care managers address practical barriers. Assign the next action explicitly so members do not have to coordinate conflicting advice themselves.

Evaluate Adherence Using the Applicable Definitions

Proportion of days covered estimates how much of a defined period medication supplies cover. Apply current drug-class, threshold, eligibility, and exclusion specifications. Dispensing evidence does not establish ingestion, clinical benefit, or appropriate continuation.

Strategy 6 | Improve Member Experience by Fixing Operational Friction

Reduce Repeated Calls, Conflicting Instructions, and Lost Referrals

Review experiences members can describe: repeating their history, calling several offices, or receiving incompatible instructions. Fixing these breakdowns improves service but does not guarantee changes in CAHPS scores.

Support Language, Accessibility, and Access Needs

Build interpreter services, accessible materials, transportation support, and realistic scheduling into outreach. A successfully delivered request cannot overcome an unavailable appointment or instructions a member cannot understand.

Use Experience Feedback to Improve Service—not Influence Responses

Analyze complaints and experience feedback for recurring service failures. Use findings to improve operations, not coach members toward favorable survey responses or selectively target those expected to provide positive answers.

Strategy 7 | Create Closed-Loop Accountability and Valid Closure Evidence

Make Ownership, Status, and Escalation Visible

Every priority gap needs an accountable team, status, aging threshold, and escalation path. NAVIGATE can support multidisciplinary workflow tracking in specialty programs; oncology time to treatment is not automatically a Star Ratings measure.

Reconcile Completed Care With Accepted Measure Evidence

Clinical completion and reportable closure differ. Reconcile claims and clinical records against applicable specifications, preserving dates and source documentation. A completed appointment does not necessarily establish that the qualifying service occurred.

Use Leading Operational Indicators Alongside Quality Results

Monitor execution before annual ratings appear. These are internal operational indicators, not CMS Star Ratings measures.