Are Improving Star Ratings Part of Your Health Plan’s KPIs This Year? Here’s What Most Plans Are Missing 

For Medicare Advantage plans, Star Ratings have always been a critical measure of quality and performance. But maintaining high ratings has become increasingly difficult. 

The numbers tell the story. The percentage of beneficiaries enrolled in 4+ Star Medicare Advantage Prescription Drug (MA-PD) plans dropped from 75% in 2024 to 62% in 2025. Meanwhile, average MA-PD Star Ratings have declined for four consecutive years, falling from 4.37 in 2022 to 3.92 in 2025.  

Much of this is attributed to the Centers for Medicare and Medicaid Services (CMS) introducing methodological and measure-level changes, including: 

• Continued phase-in of Tukey outlier deletion 

• Removal of COVID-era flexibilities 

• Measure-weighting adjustments 

• Return to more normalized cut-point calculations, which have made year-over-year performance increasingly difficult to predict and sustain 

The stakes are high. Plans that fall below 4 Stars lose access to the 5% Quality Bonus Payment (QBP) and face lower rebate percentages, creating financial pressure at a time when medical costs continue to rise, and margins remain under strain. Yet many organizations focus their efforts on the back end of the quality process—like reporting, submissions, audits, and gap closure—after the underlying data has already been created. 

This raises an important question: Are health plans trying to improve Star Ratings too late in the process? 

Performance Measurement is Just the Beginning 

When Star Ratings decline, most organizations respond by focusing solely on quality programs. They invest in HEDIS® reporting, member outreach campaigns, provider engagement initiatives, and gap closure efforts. Those activities are essential for success. But they don’t always capture the entire picture. 

By the time a measure appears on a dashboard, or a member is identified for outreach, the underlying data has already been generated. If that data is incomplete, incorrect, or delayed, every subsequent quality activity becomes more difficult. 

Predictive models become less reliable. Provider performance reporting may be misrepresented. Gap closure efforts can target the wrong members at the wrong time. Teams can spend valuable time reconciling data instead of acting on it in ways that improve results. 

The challenge isn't measuring quality but ensuring that the information used to measure quality is accurate. 

Better Star Ratings Start Upstream 

This is where many health plans have an opportunity to rethink their approach. 

Traditionally, payment integrity has been viewed as a cost-containment function focused on recovering overpayments and reducing waste. But prospective payment integrity can play a much larger role in quality performance. 

HealthEdge Source™, the industry's leading prospective payment integrity solution, helps health plans improve data accuracy before claims are paid. By validating claims against millions of payment and reimbursement rules in real time, HealthEdge Source helps ensure that the data flowing through the organization is more accurate, complete, and actionable from the start. 

That matters because many of the activities that influence Star Ratings depend on claims data. 

Accurate claims data supports more reliable HEDIS measurement and regulatory reporting. Real-time visibility into admissions can help identify members who may benefit from earlier interventions. Fewer billing errors and surprise denials can contribute to better member experience and improved CAHPS® performance.  

And by reducing the administrative burden associated with correcting payment errors after the fact, organizations can redirect resources toward initiatives that improve quality outcomes and member engagement. 

Clean Data Alone Doesn't Improve Star Ratings 

Clean claims data doesn't close care gaps. It doesn't engage members. It doesn't improve medication adherence. And it doesn't submit HEDIS measures. 

What it does do is create the conditions for those activities to be more effective. 

This is where many organizations miss an important connection. Payment integrity and quality programs are often managed as separate functions, even though they rely on the same underlying information. One team focuses on data accuracy. Another focuses on quality outcomes. 

The plans that consistently outperform their peers increasingly recognize that those efforts are interconnected. 

Turning Trusted Data into Measurable Outcomes 

Once health plans have confidence in the integrity of their data, they can focus on improving performance. 

HealthEdge Quality Solutions help organizations transform accurate data into measurable quality outcomes through Stars program management, HEDIS administration, predictive analytics, quality reporting, gap closure initiatives, and member engagement programs. 

For example, Quality360® supports HEDIS measurement and submission through an NCQA-certified measure engine, configurable data ingestion, audit-readiness capabilities, sample-and-chase management, and year-round quality monitoring. Complementary analytics and reporting tools provide executive dashboards, measure-level reporting, provider scorecards, real-time performance tracking, and predictive modeling that help plans identify opportunities before they affect Star Ratings. 

HealthEdge Stars programs extend these capabilities through consulting services, forecasting, competitive benchmarking, "Path to 4 Star" modeling, and initiative execution designed to help organizations prioritize the actions most likely to improve performance. Rather than waiting until reporting season to assess results, plans can continuously monitor performance, identify emerging risks, and intervene earlier. 

The result is a connected approach to quality improvement: 

Accurate Data → Better Insights → Targeted Action → Improved Outcomes → Higher Star Ratings 

Connecting Payment Integrity and Quality Performance 

As Star Ratings become more difficult to achieve, health plans can no longer afford to think about payment integrity and quality improvement as separate initiatives. 

One ensures the data is accurate. The other ensures that data is transformed into action. 

When these functions operate together, organizations can identify opportunities earlier, improve the effectiveness of quality initiatives, and create a more reliable path to better outcomes. 

The results demonstrate the impact of this approach.  

• HealthEdge Quality360® clients have achieved a 95%+ retrieval rate, a 100% medical record review validation pass rate, 77%+ year-over-year hybrid measure improvement, zero audit issues on retro submissions, and up to 28% Stars improvement.  

• HealthEdge's Stars programs have also helped plans achieve 4-Star and 4.5-Star ratings while delivering highly accurate forecasting and an average 3% increase in HEDIS ratings across clients. 

In today's Medicare Advantage environment, the most successful organizations won't be the ones that simply measure quality more effectively. They'll be the ones that connect data integrity, quality measurement, analytics, and member engagement into a single strategy. 

See how HealthEdge Risk & Quality solutions can enable your health plan to achieve double-digit improvements in risk score accuracy. Read the case study, “From Underperformance to a 4+ Star Rating: How HealthEdge Propelled a Health Plan to Quality Excellence and Revenue Growth.” 

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA). 

CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).