Medicare Advantage Plans Brace for Sweeping 2025 CMS Audit and Payment Rule Changes

In most years, Medicare Advantage disenrollment is a defensive problem: a plan keeps the members it has, and the losses are gradual. 2026 broke that pattern. A wave of plan exits pushed roughly 2.9 million Medicare Advantage members, about 10 percent of enrollees, out of plans that stopped serving their counties, a nearly tenfold jump from the 1 percent average that held from 2018 through 2024.¹ The market filled with switchers, and every plan is now fighting on two fronts, defending the members it has and competing for a large pool of switchers. The same thing decides both: whether the plan is easy to be a member of.

The same failure now costs a plan twice

Forced disenrollment, the county exits that drove the 2026 spike, is not a service problem, and no plan can prevent it. But everything the disruption set in motion afterward is within a plan's control. A market this unsettled taxes a weak member experience twice, once as the plan loses its own members and again as it fails to keep the switchers it wins. A new member arrives with no goodwill in reserve. A tenured member might forgive a bad call after ten good years; a member of ten days simply shops again.

Members leave for reasons a plan can see coming

On both fronts, the reasons are documented, and they are not mainly about price. In the Medicare Current Beneficiary Survey, the strongest predictors of leaving were difficulty accessing care, which raised the odds by about a third, and low plan generosity, by roughly half; cost alone was not significant once the other factors were accounted for.² CMS confirms it in its own monthly Disenrollment Reasons Survey,³ where close to a fifth of disenrollees cite problems getting services covered and roughly one in eight cite customer service.⁴ Those are the substance of member service calls.

The decision is usually audible before it is final

An honest caveat first: access and benefit design, the largest drivers, are not call center problems in origin, and listening does not widen a narrow network. What it does is surface the trouble first. Members rarely leave over a benefit design in the abstract; they phone to ask why a service was denied or a drug dropped, and hang up without an answer long before they fill out a form. A member who has called three times about one issue is not satisfied, yet first call resolution in health insurance is only about 72 percent,⁵ and for complaint calls just 47 percent.⁶ Traditional quality assurance reviews only 2 to 5 percent of calls,⁷ so the slow walk to disenrollment, and nearly every call in a language other than English, goes unheard.

Why the loss counts twice on the books

The cost shows up plainly. CMS caps broker pay at $694 for a new Medicare Advantage enrollment in 2026 and $347 for a renewal, so acquiring a member costs at least twice keeping one.⁸ In a churning market a plan pays that premium at volume, and winning a switcher only to lose them a year later to an unreviewed call means it bought nothing. On top sits the Star Ratings bonus: eligibility turns on the four star threshold, and a half star slip from 4.0 to 3.5 erases the entire 5 percent bonus,⁹ several million dollars a year for a midsize plan.

CMS just removed the disenrollment scorecard

The timing is unkind. On April 2, 2026, the Contract Year 2027 Final Rule removed 11 Star Ratings measures, including Members Choosing to Leave the Plan, the measure that graded plans on voluntary disenrollment, effective with the 2029 Star Ratings.¹⁰ That looks like relief, but nothing underneath it changed. CMS still fields the Disenrollment Reasons Survey and reports disenrollment publicly, CAHPS remains in the formula at double weight,¹¹ and a lost member still has to be replaced. CMS stopped keeping score in the very year a plan can least afford to look away.

What to look for in a way to see it coming

Finding these members while there is still time to act is a different exercise from grading agents on a sample. A plan should look for:

• Whole population analysis rather than sampling, so a single member's escalating calls and the patterns across the book are both visible.

• Scoring that reads the member, weighing sentiment, unresolved issues, and repeat contact, not just whether the agent's greeting was correct.

• The same rigor for every language, including interpreter lines, which Section 1557 of the Affordable Care Act makes a legal duty.

• Plan ownership of the data and scoring models, so the retention signal survives changes in vendors, staffing, and telephony.

• A direct link from calls to CAHPS, grievances, and disenrollment, so sentiment does not sit in a report no one connects.

This is the gap Claro by Mizzeto was built to close. Claro analyzes the full volume of member calls, including the languages and interpreter lines sampling never reaches, and its Member Sentiment & At-Risk Identification scoring surfaces the unresolved, escalating conversations that turn into disenrollment months later, for tenured and newly won members alike, while the plan keeps ownership of the data. For the upstream work, see how payers can fix their call centers.

The bottom line

For one year at least, retention is a contest a plan can lose on both sides at once. The reasons people leave Medicare Advantage plans are documented, they turn on usability more than price, and they surface on calls long before an enrollment form, for members of a decade or a week. CMS took away the measure. The cost, paid twice over in a churning market, did not fall.

References

1.  Johns Hopkins Bloomberg School of Public Health and Georgetown University, JAMA (Feb. 18, 2026): approximately 2.9 million Medicare Advantage members, about 10 percent of enrollees, faced forced disenrollment for 2026 as plans exited markets, up from a mean of 1 percent from 2018 to 2024 and 6.9 percent in 2025. jamanetwork.com

2.  Health Affairs, study of Medicare Advantage disenrollment using the Medicare Current Beneficiary Survey (2015 to 2020): difficulty accessing care associated with roughly 1.33 times greater likelihood of disenrollment; low plan generosity roughly 1.47 times; dissatisfaction with care quality significant; dissatisfaction with cost alone not a significant independent predictor (approx. 1.03 times). healthaffairs.org

3.  Centers for Medicare and Medicaid Services, Medicare Advantage and Prescription Drug Plan Disenrollment Reasons Survey. Captures why beneficiaries voluntarily leave; results publicly reported in the annual Star Ratings Data Table and Display Measures. cms.gov

4.  The Commonwealth Fund, analysis of CMS Medicare Advantage Disenrollment Reasons Survey data: approximately 18 percent of disenrollees cited problems getting the plan to cover services and approximately 13 percent cited customer service issues such as trouble obtaining accurate information; voluntary disenrollment across MA contracts rose about 70 percent between 2017 and 2021. commonwealthfund.org

5.  SQM Group, First Call Resolution Benchmarking by Industry: health insurance first call resolution approximately 72 percent. sqmgroup.com

6.  SQM Group, first call resolution by call type: complaint calls resolve on first contact approximately 47 percent of the time, the lowest of all call types. sqmgroup.com

7.  SQM Group, call center quality assurance benchmarking: traditional programs review roughly 2 to 5 percent of interactions. sqmgroup.com

8.  Centers for Medicare and Medicaid Services, Agent and Broker Compensation memorandum for Contract Year 2026 (June 18, 2025): national maximum Fair Market Value of $694 for a new Medicare Advantage enrollment and $347 for a renewal. cms.gov

9.  Centers for Medicare and Medicaid Services, Medicare Advantage Quality Bonus Payment methodology: bonus payments apply to contracts at or above the four star threshold; loss of four star status removes the 5 percent quality bonus applied to the benchmark. cms.gov

10.  Centers for Medicare and Medicaid Services, Contract Year 2027 Medicare Advantage and Part D Final Rule (April 2, 2026): removal of 11 Star Ratings measures, including Members Choosing to Leave the Plan, effective with the 2029 Star Ratings. cms.gov; Federal Register, April 6, 2026.

11.  Centers for Medicare and Medicaid Services, 2026 Medicare Part C and D Star Ratings Technical Notes: CAHPS and patient experience measure weights reduced from quadruple (4x) to double (2x) effective with the 2026 Star Ratings. cms.gov

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By the time a formal grievance reaches a health plan’s Grievance and Appeals team, it arrives looking like an emergency. The member is angry. A response deadline is already running. A regulator may eventually read the file. What the file rarely shows is that the grievance did not begin that week, or even that month. It began on an ordinary call that did not get resolved and was never reviewed. The warning was there. No one was assigned to look for it.

Most health plans treat reducing member grievances as a downstream chore: staff the queue, meet the deadline, close the case. That posture quietly concedes the grievance as inevitable, and it is not. A grievance is the visible end of an escalation that usually runs about six weeks, and nearly all of it is recorded, in the plan’s own phone system, in the member’s own words. The signal is not missing. It is simply never listened to.

A grievance is a six week escalation, not a single event

CMS defines a grievance as a complaint about a plan’s delivery of service, and the rules let a member arrive there slowly. A Medicare Advantage enrollee has up to 60 days after the triggering event to file, and the plan then has 30 days to resolve a standard grievance, with a 14 day extension.⁵ That window is the outer edge of a story that almost always starts earlier, on the phone.

The arc is familiar to any member services team. It opens with a single call about a denied claim, a benefit change, or a stalled prior authorization, and the member hangs up with an answer that is incomplete or simply wrong. That is common. SQM Group puts first call resolution for health insurance at roughly 72 percent, so close to three in ten member calls are not settled the first time.¹ The member calls back, and calls again, and these repeat calls are the hardest to fix, because complaint calls resolve on the first contact only 47 percent of the time, the lowest rate of any call type SQM tracks.² By the fifth or sixth week the member gives up and files. Only then does the plan open a case.

The shape of it is mundane. A member is told on the phone that a drug is covered, learns at the pharmacy counter that it is not, gets a different answer from a second agent, and files after a third. Three recorded calls, one avoidable grievance, and a member now drifting toward disenrollment. Every call was captured. None was flagged.

Appeals run on the same current. A denial explained badly prompts an appeal, not just frustration. The recording of that call is the clearest account of what the member was told, and the one document the appeals file rarely contains. A single unreviewed call can feed both outcomes, a grievance about the service and an appeal against the decision, both audible weeks before either was filed.

Why the warning stays invisible

The reason is not indifference. It is arithmetic. Traditional call center quality assurance, whether member service is run internally, outsourced, or split between the two, reviews somewhere between 2 and 5 percent of calls.³ The other 95 percent, which includes nearly every repeat call in an escalating grievance, is never heard by anyone whose job is to catch problems. A sample that small will almost never contain the three or four particular calls that make up one member’s slow walk to a filing, and it is even less likely to reveal the shape of the trouble when the same benefit is being miscommunicated to hundreds of members at once.

Sample size is only half of the failure. The deeper flaw is what the sampling was built to measure. A conventional scorecard asks whether the agent greeted the member, verified identity, and read the required disclosures. It does not ask whether the member’s problem was actually solved, or whether the member hung up angrier than they picked up. A call can earn a clean score and still be a grievance in motion. The program was designed to grade etiquette, and etiquette is not the thing that turns into a filing. We have made this case before, that most grievances start as calls that never got reviewed, and nothing in the underlying mechanics has changed since.

The calls in languages other than English are the least visible of all. When a member with limited English proficiency cannot be helped without an interpreter, the quality of the resolution is harder to verify, the member is less likely to push back on an answer they do not fully understand, and the interaction is almost never scored at all. Those are precisely the calls where a small misunderstanding hardens, unseen, into a grievance.

CMS just removed your grievance scorecard

On April 2, 2026, CMS issued the Contract Year 2027 Medicare Advantage and Part D Final Rule and, with it, removed 11 measures from the Star Ratings. Four of them speak directly to this problem, and all four leave the formula beginning with the 2029 Star Ratings: Complaints about the Health and Drug Plan, Members Choosing to Leave the Plan, Plan Makes Timely Decisions about Appeals, and Reviewing Appeals Decisions.⁴ Read in a hurry, that looks like a reprieve. The measures that once turned complaints, disenrollment, and appeals handling into a Star score are going away, and the natural temptation is to slide grievance and appeals monitoring down the list of things worth watching.

That reading has it exactly backward. The measures are leaving the scorecard. The exposure is staying exactly where it was. CMS still runs the Complaints Tracking Module, and plans are still bound to the resolution timelines set at 42 CFR 422.125 and 422.564.⁵ The complaint and customer service questions remain on the CAHPS survey, and the survey based measures carry heavy and rising weight in the Medicare Advantage formula.⁶ A member who leaves still leaves. What actually changed is narrower and more dangerous than relief: the warning light that used to sit on the Star dashboard has gone dark. Plans that had quietly relied on those measures as their grievance scorecard now have no scorecard, and precisely the same risk underneath it.

What it takes to see it coming

Seeing a grievance coming means catching the escalation while it is still a service problem, not a case number. It rests on a reversal: stop sampling calls to grade agents, and start reading all of them to find members. A plan that analyzes every interaction can connect the several calls behind one escalation and watch the same complaint surface across the population, where a single systemic fix replaces hundreds of grievances not yet filed.

The point is not more scores but earlier ones. A member who has called three times about one decision is a retention risk however politely each call was handled, and no rubric that grades greetings will say so. A few practical tests separate a system that sees a grievance coming from one that only counts calls afterward:

• Whole population analysis, not sampling, so one member’s escalating calls and the patterns forming across the book are both visible before anyone files.

• Scoring that reads the member, not just the agent, weighing sentiment, unresolved issues, and repeat contact rather than whether the greeting was correct.

• The same rigor for calls in every language, including interpreter lines, because that is where hidden escalation collects and Section 1557 makes language access a legal duty.

• Plan ownership of the conversation data, scoring models, and trend lines, so the early warning system survives changes in telephony and staffing and can be retuned in days.

• Alerts that reach the people who can act, so member services, grievance and appeals, and compliance see a trend while there is still time to intervene.

Two ways to run grievance and appeals operations

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Mizzeto built Claro for exactly this gap. It analyzes the full volume of member calls, including the ones in other languages and on interpreter lines that sampled QA never reaches, and its Member Sentiment & At-Risk Identification scoring is built to surface the unresolved, escalating conversations that become grievances and appeals weeks later, all while the plan keeps ownership of the underlying data and the logic that scores it. If a grievance and appeals team is meeting every deadline and still watching volume climb, the explanation is usually sitting in calls the plan has already recorded and has never had a way to hear.

The bottom line

A formal grievance is the most expensive way a health plan can learn about a problem it could have seen six weeks earlier. The information was never missing. It was sitting, unheard, in the 95 percent of calls no one reviews. CMS has taken away the measures that once forced plans to watch their complaints and their appeals, but the price of a grievance, paid in CAHPS, in disenrollment, and in compliance exposure, has not fallen by a cent. Reducing member grievances begins with a decision to stop waiting for them to arrive.

Any plan can find out what its own calls are already saying. Mizzeto will score a sample of them and show a plan the warnings hidden inside before it commits to anything further. For the upstream work that keeps these calls from going wrong in the first place, see how payers can fix their call centers.

References

1.  SQM Group, “First Call Resolution Benchmarking by Industry” (health insurance first call resolution approx. 72 percent). sqmgroup.com

2.  SQM Group, first call resolution by call type (complaint calls resolve at 47 percent, the lowest of all call types). sqmgroup.com

3.  SQM Group, call center quality assurance benchmarking (traditional programs review roughly 2 to 5 percent of interactions). sqmgroup.com

4.  Centers for Medicare & Medicaid Services, “Contract Year 2027 Medicare Advantage and Part D Final Rule,” April 2, 2026 (removal of 11 Star Ratings measures, including Complaints about the Health and Drug Plan, Members Choosing to Leave the Plan, Plan Makes Timely Decisions about Appeals, and Reviewing Appeals Decisions, effective with the 2029 Star Ratings). cms.gov; Federal Register, April 6, 2026.

5.  42 CFR 422.564 (grievance procedures: 60 day filing window, 30 day standard resolution, 14 day extension) and 42 CFR 422.125 (resolution of complaints in the Complaints Tracking Module). ecfr.gov

6.  Analysis of the CY2027 Final Rule finding relative Star Ratings weight shifting toward survey based measures such as CAHPS for Medicare Advantage plans (e.g., Crowell & Moring; Holland & Knight client alerts, April 2026).

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Most health systems measure patient experience after it is over. The survey arrives weeks after the visit, asks about the physician, the nurse, and the discharge instructions, and lands as a number on a dashboard a full quarter after the care happened. By the time anyone reads it, the experience is already history.

For a large share of patients, though, the experience did not begin in the exam room. It began on the phone. It began when they called to book an appointment, asked a question about a bill, tried to reach someone in a language other than English, or waited on hold to learn whether a procedure was covered. That first call sets the tone for everything that follows, and most organizations have almost no visibility into how it went.

The call center is the front door to the health system, and also the least measured room in it. Most organizations review fewer than 5 percent of their calls, which means the interactions that decide whether a patient stays or leaves are usually the ones nobody hears. You cannot improve an experience you only sample. This article looks at why patient experience starts in the call center, what it costs when those calls go unreviewed, and what to look for in a way of measuring them that does not depend on a survey arriving months too late.

The first impression is usually a phone call

The first call is the first test of the relationship, and patients grade it against every other service they use. In a recent Harris Poll, 61 percent of Americans said they want their healthcare experience to feel more like a convenience app such as Amazon Prime or Uber, and 60 percent said they find the process of seeing a new provider frustrating.¹ For most of them, that judgment forms on the phone.

That call carries more weight than it appears to. Accenture, which has surveyed more than 21,000 consumers on healthcare experience, found that 30 percent of patients selected a new provider in 2021, and that nearly 80 percent of those who switched cited poor navigation factors as the reason, including difficulty doing business and bad experiences with administrative staff.² Navigation and administrative staff are not abstractions. They are the scheduling line, the billing line, and the front desk phone.

What this looks like in practice is familiar. A patient calls to schedule, gets transferred twice, sits on hold, never gets a clear answer about cost, and quietly books somewhere else. No survey ever captures that call, because the caller never became a patient. They simply did not come back.

The survey is a rear-view mirror

Patient experience surveys are valuable, but they share a structural limitation. HCAHPS for hospitals and CG-CAHPS for medical groups measure experience after the fact, on a sample of patients, and report it weeks or months later. They tell you what happened. They cannot tell you what is happening right now, while you can still do something about it.

A survey score also cannot explain itself. It can tell you a patient rated you a six. It cannot tell you that the patient was transferred three times trying to reschedule, that your Spanish-speaking callers are routinely routed to English-only agents, or that a billing conversation went sideways and broke trust. The reason behind the score lives in the call, not in the survey.

And the score is not a vanity metric. Through the CMS Hospital Value-Based Purchasing program, 2 percent of a participating hospital’s Medicare payments are withheld and redistributed based on performance, and the patient experience domain measured by HCAHPS accounts for 25 percent of the Total Performance Score.³ For a mid-sized hospital, that is millions of dollars tied to patient experience, a meaningful share of which is shaped before the patient ever arrives for care. That direct exposure is the hospital case. Physician groups do not sit under Hospital Value-Based Purchasing, but they answer to their own version through CG-CAHPS and value-based programs such as MIPS. The mechanism differs by setting. The underlying point does not: the experience that drives the score is built on calls, and it is rarely captured by them.

The calls that matter are the ones you never hear

Here is the part that does not get said often enough. Traditional manual call quality assurance reviews a small fraction of total calls, typically less than 5 percent. This is not a failure of the people doing the work. A human QA team, however skilled, can only listen to so many calls in a day. It is a limitation of the measurement model, and it holds true whether your contact center is in-house, outsourced, or a combination of both.

The problem is what that small sample misses. The calls that drive complaints, switching, and low scores are outliers by definition, and a random sample of a few percent is structurally poor at finding outliers. The frustrated caller, the dropped handoff, the limited English patient who never got a qualified interpreter: these are precisely the calls that fall outside the sample. The 95 percent nobody reviews is exactly where the risk lives.

When you can only see a sliver, you end up managing to averages. Average handle time, abandonment rate, and service level tell you the center is busy. They do not tell you whether patients felt heard, whether a financial conversation damaged trust, or whether a caller is one bad interaction away from leaving. The warning signs of a patient about to switch are audible long before they ever surface in a survey: repeat calls about the same unresolved issue, rising frustration in a caller’s tone, questions that never get a straight answer. Caught in the moment, those are coachable and fixable. Caught in a survey a quarter later, they are already lost revenue and a lower score.

What to look for in a way to measure patient calls

The goal is not to survey harder. It is to actually hear what happens on your calls, all of them, in a way you can act on. When evaluating how to do that, whether your contact center is run in-house, through a partner, or as a hybrid, look for a few things.

• Full coverage, not a sample. The system should review 100 percent of calls, not the small share a manual team can reach. Outliers only become visible at full coverage.

• Experience, not just compliance. It should score patient sentiment and the quality of agent communication, not only whether a script was followed. Compliance checklists miss the human signal that actually moves HCAHPS.

• Every language, automatically. Non-English calls should be reviewed the same way English calls are. Section 1557 of the Affordable Care Act requires meaningful access for patients with limited English proficiency,⁴ so a tool that cannot read those calls leaves both an experience gap and a compliance gap.

• Real time, not retrospective. It should surface issues while you can still intervene, not weeks later. A survey is a rear-view mirror. Live call intelligence is a windshield.

• Owned by your organization. You should own the data and the real-time intelligence so your teams can act on it directly and continuously, rather than at quarterly reporting intervals.

• Built to fit your stack. It should connect to the systems you already run, without a disruptive replacement project.

The difference between the two models is the difference between knowing your score and knowing why you earned it.

This is the gap Claro by Mizzeto was built to close. Claro is an AI-powered contact center intelligence platform that audits 100 percent of patient and provider calls, including calls in languages other than English, scoring patient sentiment, agent communication, and compliance in real time rather than on a sample weeks after the fact, and it connects to the systems you already use. The result is the ability to see and coach to what is actually happening on every call, in every language, instead of inferring it from a fraction of them. You can read more about how this reshapes day-to-day operations in our overview of modern call center operations.

The bottom line

The visit is not where patient experience begins. For a growing share of patients, it begins on the phone, and it often ends there too, before anyone in a white coat is involved. Health systems have spent years measuring experience after the fact and running the contact center to averages, while the moments that decide loyalty, reputation, and a meaningful slice of value-based reimbursement play out on calls nobody hears.

The organizations that move first to hear every call, in every language, as it happens will hold a real advantage: stronger HCAHPS performance, better patient retention, and operational decisions grounded in what patients actually experienced rather than what a delayed survey implied. Patient experience starts on the phone. The only question is whether you can hear it.

References

1. Medical Economics, “69% of patients would switch providers for better services” (The Harris Poll), 2026. medicaleconomics.com

2. American Hospital Association, “Why Patients Leave: 4 Nonnegotiable Consumer Expectations” (Accenture consumer research), 2023. aha.org

3. Centers for Medicare and Medicaid Services, “Hospital Value-Based Purchasing.” cms.gov

4. HCAHPS and Hospital VBP, Patient Experience of Care domain weighting. hcahpsonline.org

5. U.S. Department of Health and Human Services, Office for Civil Rights, Section 1557 non discrimination final rule, 2024. hhs.gov

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How call intelligence catches member complaints before they reach your grievance and appeals team

Every health plan has a grievance and appeals operation. Staff, timelines, case management workflows, regulatory tracking. For Medicare Advantage plans, CMS audits it. For Medicaid plans, states audit it. The compliance burden is real. The operational cost is real.

What most plans have not built is anything upstream of it.

A formal grievance is not where the problem starts. It is where the problem ends up after several earlier opportunities to fix it were missed. A member's prior authorization status was communicated incorrectly. A benefit change was explained poorly and the member hung up confused. An agent gave a formulary answer that turned out to be wrong. None of those calls showed up in the QA report, because the QA program reviewed 2 to 5 percent of call volume^[1] and these particular calls were not in the sample. Weeks later, the member called back. Then again. Then filed.

This is the upstream problem that most health plan grievance operations are not resourced to see. The tools needed to catch it simply have not been part of how call center quality has historically worked.

What grievances are actually made of

CMS defines a grievance as a complaint about a plan's delivery of service. That definition covers a wide range of situations: an agent who was dismissive, a hold time that felt unreasonable, a coverage question that went unanswered. The operational category that generates the most preventable grievances is simpler than the regulatory definition suggests.

Most formal grievances start as an unresolved phone call.

SQM Group's benchmarking data puts the healthcare insurance call center first call resolution rate at approximately 72 percent^[2], meaning roughly 28 percent of member calls do not get resolved on first contact. Some of those members call back once. Some call back twice. When the calls involve a coverage dispute, a prior authorization denial, or a benefit question with real financial consequences for the member, the escalation path eventually leads to a formal grievance.

The more telling finding is about complaint calls specifically. The FCR rate for interactions where a member is already expressing dissatisfaction is only 47 percent.^[3] Less than half of the calls most likely to become a grievance get resolved on the first contact. Plans are sending a continuous stream of unresolved member issues toward the back end operations that cost the most to run.

There is a second finding worth flagging here. SQM's research estimates that approximately 14 percent of callers describe their call as a complaint call. Most contact centers believe that number is under 5 percent.^[4] Complaint volume is substantially underreported. Plans are not just missing the resolution. They are missing the signal that a problem exists at all.

The enforcement environment has changed

In January 2026, California's Department of Managed Health Care fined Anthem Blue Cross $15 million for what it described as longstanding and widespread deficiencies in handling member grievances spanning more than 15 years.^[5] The action included a requirement for an independent auditor to oversee grievance system corrections for up to four years. This was not the first enforcement action for the same pattern. Prior survey findings had not produced sustained correction.

The pattern regulators are reacting to is not primarily about whether a plan has a compliant grievance process on paper. It is about whether grievances are actually resolved. A well documented compliance framework that leaves a significant share of complaints unresolved is still a regulatory liability.

CMS also removed the Complaints about the Health Plan and Complaints about the Drug Plan measures from the Star Ratings formula, effective with the 2029 Star Ratings.^[6] The instinctive response to that change is to treat complaint monitoring as less important. That is the wrong conclusion. CMS retains these as display measures, complaint trends are widely regarded in payer operations as leading indicators of CAHPS deterioration, and enforcement authority over grievance handling is completely independent of Star Ratings. The scorecard accountability signal is gone. The underlying compliance exposure is not.

What the call reveals that the grievance does not

By the time a formal grievance reaches the G&A team, the plan already has a documentation obligation, a response deadline, and a case that may be reviewed by a regulator. What the plan usually does not have is insight into the original interaction.

Not because the call was not recorded. Most plans record calls. But because the call was not analyzed. Nobody reviewed what the agent communicated about the prior authorization decision, whether the member left with an accurate understanding of their coverage, or whether the issue raised on that call had appeared on 200 other interactions in the previous 30 days.

That missing analysis is the upstream gap. A grievance intake form tells the plan what the member is upset about now. The original call tells the plan what actually happened, who was responsible, whether it was an agent accuracy issue or a systemic script failure, and whether the same pattern is playing out across hundreds of calls currently in queue.

When plans close that gap, the economics look different. Processing a formal grievance costs real money in staff time, documentation, and in some cases regulatory engagement. Catching the underlying issue in the call costs a fraction of that. The intervention point is upstream, and it is the cheaper one.

The call types most likely to generate a formal grievance follow a recognizable pattern. Each one shares the same underlying failure: an interaction that ended without resolution, with no mechanism to catch it before the member decided to escalate.

The language access dimension

Non-English member calls carry a disproportionate share of the upstream grievance risk. When a limited English proficient member reaches an agent who cannot serve them without an interpreter, resolution quality is harder to verify, the member is less likely to push back on an unclear answer, and the interaction is almost never scored in a traditional QA program.

The CY2027 Final Rule removed the Call Center Foreign Language Interpreter and TTY Availability measure from Star Ratings, effective with the 2029 Star Ratings.^[7] Plans may read that as reduced pressure on language access. The old measure rewarded having an interpreter line available. The bar has shifted. LEP member dissatisfaction with service quality now surfaces in overall CAHPS scores, and those scores carry direct financial consequences for Medicare Advantage plans. It shows up 12 to 18 months after the interaction.

Plans that do not score non-English calls with the same rigor as English calls have a quality gap that will surface in member satisfaction surveys and, for Medicare Advantage plans, directly in CAHPS scores. It will just arrive on a delay.

What to look for in a solution

If you are evaluating call intelligence for this purpose, these are the capabilities that actually matter:

100 percent call coverage, not sampling. The interactions that generate formal grievances are rarely in a 2 to 5 percent random sample. Full coverage is what makes upstream intervention possible.

Root cause analytics, not just QA scores. An agent compliance score tells you whether the script was followed. It does not tell you why members are calling back about the same issue or whether a benefit change was communicated incorrectly across an entire team. Systemic failure identification is what separates a grievance prevention tool from a QA scorecard.

Linkage between call data and G&A intake. If a formal grievance arrives and the underlying call is retrievable, analyzable, and traceable to a root cause, that is a materially different case than one built from member description alone. The connection between call intelligence and grievance case management is where the prevention value is.

Native language quality monitoring. Non-English calls should be scored in the language they were conducted, not translated after the fact and then graded. Post hoc translation loses the nuances that determine whether a member actually understood the answer they received.

Plan ownership of the underlying data. If call recordings, transcripts, and scoring models belong to a vendor rather than the plan, the plan cannot connect call intelligence to its own member satisfaction data, grievance analytics, and retention tracking. That intelligence needs to stay with the plan.

How Claro by Mizzeto approaches this

Claro by Mizzeto was purpose built for health plans and analyzes 100 percent of member interactions across languages, scoring every call against six dimensions: CMS guidelines compliance, HIPAA compliance, resolution rate, CMS accuracy, member sentiment, and communication and empathy. Automated post call translation of non-English interactions is the enabling capability that makes scoring in any language possible. Call data stays with the plan. For related context, see Are Health Plans Really Listening to All Their Members? and our guide to how payers can fix their call centers.

The bottom line

Grievance volume is a lagging indicator. By the time a formal complaint reaches the G&A team, the call that caused it has already happened, the member's patience has already worn out, and the cheap intervention window has already closed. The plans that reduce preventable grievances are not the ones that build bigger G&A teams. They are the ones that get visibility into every call before the member decides to escalate.

The data is already in the call recordings. The question is whether the plan is actually looking at it.

References

1. SQM Group. Published guidance on manual QA sampling rates, noting that most contact centers review 2 to 5 percent of call volume. https://www.sqmgroup.com/software  

2. SQM Group. Call Center FCR Benchmark Results by Industry. Healthcare insurance industry first call resolution rate cited at approximately 72 percent. https://www.sqmgroup.com/resources/library/blog/call-center-fcr-benchmark-2024-results-by-industry  

3. SQM Group. Top 10 Reasons for Repeat Call Complaints. FCR rate for complaint calls cited at 47 percent. https://www.sqmgroup.com/resources/library/blog/customer-complaint-calls  

4. SQM Group. Top 10 Reasons for Repeat Call Complaints. Discrepancy between actual complaint call volume (approximately 14 percent) and the typical contact center estimate (under 5 percent). https://www.sqmgroup.com/resources/library/blog/customer-complaint-calls  

5. California Department of Managed Health Care. Press release: DMHC fines Anthem Blue Cross $15 million for longstanding and widespread failures with member complaints. January 30, 2026. https://www.dmhc.ca.gov/Resources/Newsroom/PressReleases/January30,2026.aspx  

6. Centers for Medicare and Medicaid Services. Contract Year 2027 Medicare Advantage and Part D Final Rule, April 2026. Complaints about the Health Plan and Complaints about the Drug Plan measures removed from Star Ratings, effective with the 2029 Star Ratings.

7. Centers for Medicare and Medicaid Services. Contract Year 2027 Medicare Advantage and Part D Final Rule, April 2026. Call Center Foreign Language Interpreter and TTY Availability measure removed from Star Ratings, effective with the 2029 Star Ratings.

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