In Medicare Advantage, a plan’s Stars rating isn’t just a quality scorecard. It’s a financial instrument.
Plans that earn four or more stars are eligible for quality bonus payments and a higher rebate percentage, which they can reinvest in benefits to attract and retain enrollment. Plans below four stars do not. And only about 40% of Medicare Advantage plans with prescription drug coverage will earn four or more stars in 2025, a decline from 42% in 2024 and 68% in 2022.
The competitive stakes have never been higher, and the data suggests that provider data accuracy is quietly pulling ratings down.
The Star Decline Is Real, and Accelerating
Only seven MA-PD contracts earned five stars for 2025, a dramatic drop from 74 contracts that earned five stars in 2022. Plans that earn four stars receive a 5% increase in their benchmark as a quality bonus payment. Plans with five stars have a strategic advantage of marketing their products year-round, not just during the short open enrollment period.
In 2025, the program paid at least $13 billion for MA quality bonuses, over four times more than 10 years earlier. That bonus pool is the prize. And it flows to plans that can demonstrate quality, access, and member experience, all of which depend, more than most plans acknowledge, on the accuracy of their provider data.
Achieving four or more stars is critical because it qualifies the health plan for the quality bonus payment and a greater rebate percentage. The plan can reinvest both into benefits that make products more attractive, driving growth and financial performance. Plans below that threshold cannot compete on benefits in the same way. The Stars gap compounds: accurate data supports better ratings, which funds better benefits, which drives enrollment growth, and the inverse is equally true.
The Mechanism: How Provider Data Errors Impact Star Ratings
This is where the connection becomes direct and operational, not theoretical.
Several of the measures that drive Star ratings are directly degraded by provider data inaccuracies. CAHPS survey scores, which capture member experience, are significantly influenced by whether members can actually reach and see the providers listed in their plan’s directory. When a member calls a listed specialist who is no longer in-network, has moved locations, or is not accepting new patients, that is not just a member experience failure. It is a CAHPS event. Complaint rates go up. Care navigation scores go down. Access to care ratings erode.
According to Atlas Systems’ 2025 Member Experience Monitor research, 58% of provider directory users have encountered incorrect information. Even more concerning: 80% say these errors made them trust their health plan less. That erosion of trust is not abstract. It feeds directly into the survey-based measures that CMS uses to calculate Star ratings.
The GAO identified this structural gap a decade ago and the problem has only intensified. CMS does little to assess the accuracy of the network data in applications MA organizations submit, even though the submissions contain the same data elements as provider directories, which have been shown to be inaccurate in a number of government and private studies. The compliance burden, in other words, sits squarely on the plan. If the data submitted is wrong, and most of it is, the plan owns the consequence: through regulatory exposure, member dissatisfaction, and Stars degradation.
The Behavioral Health Crisis: A Direct Stars Risk
The 2025 CMS final rule added outpatient behavioral health as a new facility-specialty category for network adequacy evaluation. To ensure the quality of care and to prevent the formation of “ghost networks,” specific criteria were set for including nurse practitioners, physician assistants, and clinical nurse specialists in the network adequacy standard for this category. Plans must now independently verify that listed behavioral health providers have furnished services to at least 20 patients within the prior 12 months.
This matters enormously, because the behavioral health ghost network problem is severe. A 2025 HHS Office of Inspector General review found the numbers alarming. On average, 55% of providers listed in Medicare Advantage plans’ behavioral health networks were inactive. Of those, 72% should not have been included in the plans’ networks, for reasons such as providers no longer working at listed practice locations, or indicating they would not see patients enrolled in the plan.
A Senate Finance Committee secret shopper study of 120 mental health provider listings across 12 Medicare Advantage plans found that staff were only able to make appointments with providers 18% of the time. Over 80% of the listed providers were “ghosts,” either unreachable, not accepting new patients, or not in-network.
These are not just compliance failures. They are Stars failures. Access to behavioral health care is now a tracked network adequacy requirement for MA plans, and a plan that cannot verify its behavioral health providers are real, reachable, and active is operating on a foundation of data fiction, one that regulators are now equipped to interrogate.
The Compounding Disadvantage for Plans Below Four Stars
The financial architecture of MA creates a reinforcing loop that punishes plans with provider data problems, because moving from 4.5 to five stars does not provide a rebate or quality bonus payment advantage, but plans with five stars have the strategic advantage of marketing their products year-round, not just during the short open enrollment period in October through December.
Five-star plans can enroll members switching from lower-rated MA plans year-round, as opposed to only during Medicare’s designated enrollment periods, and CMS can terminate MA plans that achieve fewer than three stars three years in a row.
Plans that lose access to quality bonus payments cannot reinvest in benefits at the same level. They cannot market as aggressively. They attract fewer new members. And as their member base ages and churns, the cost to acquire and retain members increases. Plans below four stars are not just leaving bonus money on the table. They are structurally disadvantaged in their ability to compete, grow, and sustain operations over time.
For plans carrying provider data quality problems, this is not a one-year impact. It is a diversion of strategic trajectory.
The Reframe: Stars Strategy Is Provider Data Strategy
Organizations investing in Stars improvement typically focus on HEDIS measures, CAHPS survey response rates, and pharmacy adherence programs. These are legitimate levers. But they are downstream interventions.
Provider data accuracy is upstream. When a member cannot reach a listed provider, the CAHPS score is already affected before any survey is fielded. When a behavioral health provider listed in the network has not seen a plan member in over a year, the network adequacy evaluation is already at risk before the application is filed. When a specialist is listed at a location they left 18 months ago, the member complaint is already forming before any Stars improvement initiative is launched.
The instinct to treat provider data as a compliance and operations problem, and Stars improvement as a separate quality initiative, misses the connection that runs directly between them. In Medicare Advantage, the data infrastructure that supports your directory is the same infrastructure that determines whether your members can access the care you have promised them, and whether CMS rates your plan as having delivered it.
Provider data accuracy is not a supporting function for Stars strategy. In a market where only seven MA plans earned five stars in 2025, down from 74 in 2022, it may be the most underinvested lever available.
What “Getting Ahead of This” Actually Requires
The plans that will recover Stars ratings and sustain competitive positioning are the ones that stop treating provider data as a periodic cleanup problem and start treating it as a continuously validated operational layer, one that connects to member experience, network adequacy, and compliance in real time.
That means continuous ingestion and reconciliation against authoritative sources, not monthly or annual roster refreshes. It means identity resolution across credentialing, contracting, and directory systems, not siloed updates that drift out of sync. It means verifiable behavioral health network accuracy, not directory submissions that rely on provider attestations that are months stale by the time they are reviewed.
What Can Be Done?
Polus™ HCP was built for this moment, because the MA Stars problem is, at its core, a provider data infrastructure problem. Plans that close that gap do not just improve their compliance posture. They improve the member experience that drives CAHPS scores, the network accuracy that satisfies CMS adequacy reviews, and the operational credibility that sustains quality bonus eligibility year over year.
Is your provider data silently affecting your Stars? Let’s have a working conversation about your current data posture, verification cadence, and where provider data may be creating Stars exposure not yet quantified. Schedule a 30-min Data Strategy Session → No product demo. No sales pitch.
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