BluePeak Advisors was established in 2010 by a group of government healthcare professionals dedicated to solving the Medicare Part C and D Programs’ unique regulatory and operational challenges. Led by Principals Babette S. Edgar and Sherry Pound, our team of consultants consists of senior level managed care professionals, experienced clinicians and former Centers for Medicare and Medicaid (CMS) regulators who have worked at health plans, pharmacy benefit managers (PBMs), and CMS. The team consists of career government healthcare professionals with the experience and expertise to service our clients across the country. BluePeak’s focus lies in PBM and health plan operations, Medicare compliance and STARs, CMS advocacy and support, pharmaceutical manufacturer marketing and payer strategies for reimbursement, clinical programs strategies and integration and data analytics.

Highlights:

  • Worked with most of the large, medium and many of the small and growing PBMs over the past 7 years. The most common projects include:
    • Compliance: Medicare mock operational audits and audit preparation, CMS program audit assistance, mock and CMS validation audits, policy and procedure development and refinement, CMS regulations and HPMS policy interpretation and business deployment, compliance training for all operational areas, development of monitoring and oversight programs across all operational areas and for downstream vendors.
    • Operations: Enhancing processes and provision of practical solutions to meet operational compliance across all areas, claims processing enhancements, staffing planning and efficiencies, marketing and sales strategies, provision of interim staffing, training across all areas with an emphasis on customer service, coverage determinations, organization determinations, appeals and grievances, CMS Medicare plan application and implementations, and development of PBM business to accept Medicare plans from an operational and compliance perspective.
    • Strategy: Medicare product strategy and development, Medicare product pricing, claims processing strategies, insourcing vs. outsourcing of products and solutions.
  • Worked with over 75 health plans including large national, Blues, regional and local plans with MA, MA-PD, Part D and EGWP
    • Compliance: Medicare mock operational audits and audit preparation, CMS program audit assistance, mock and CMS validation audits, for Part C, Part D, SNPs and EGWPs, CMS sanction remediation, policy and procedure development and refinement, CMS regulations and HPMS policy interpretation and business deployment, compliance training for all operational areas, development of monitoring and oversight programs across all operational areas and for downstream vendors.
    • Operations: Enhancing processes and provision of practical solutions to meet operational compliance across all areas, RFP support for PBM, enrollment or other vendors, claims processing enhancements, staffing planning and efficiencies, marketing and sales strategies, provision of interim staffing, training across all areas with an emphasis on customer service, enrollment, sales, coverage determinations, appeals and grievances, STAR program enhancements for Parts C and D, CMS Medicare plan application and implementations, and development of new Medicare plans from commercial or Medicaid plans.
    • Strategy: Medicare product strategy and development, vendor insourcing vs. outsourcing of products and solutions with RFP support.
  • Over 30 large, mid-size, small and biotech pharmaceutical company manufacturer clients
    • Medicare and managed care market support
    • Marketing strategy and product planning services
    • Product reimbursement strategies
    • Strategic planning for all market segments
    • CMS policy interpretation
    • HPMS Memo Service
    • Contracting and customer strategies
    • CMS advocacy
    • Data analysis services
    • Advisory board moderation and development
    • White Papers
  • Significant work with businesses that service the healthcare market
    • Medicare product strategies that service health plans and PBMs
    • Operational and compliance assistance to law firms on Medicare issues
    • Expert witness testimony for Medicare and other pharmacy issues
    • Due diligence for investment companies
    • Strategy assistance for companies desiring to enter the PDP or EGWP business