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BluePeak Advisors can provide health plans and pharmacy benefit managers assistance with Part C and D Medicare operations remediation and efficiencies.

BluePeak will prepare health plans and PBMs for CMS Program audits by performing mock CMS audits utilizing CMS protocols, reviewing operational area universes for compliance, supporting your teams during the actual CMS audits, assisting with writing corrective action plans and providing validation audits before CMS returns.

Medicare, the Exchanges and other government programs are evolving on a daily basis. BluePeak can provide health plans, Employer Group Waiver Plans (EGWPs) and PBMs strategic direction for product development and expansion both from a business growth perspective as well as from an internal support need.

BluePeak is pleased to offer online and instructor-led training, anytime, anywhere. Our training covers a wide range of government health related topics and can be delivered online, in person or via webinar. Our training focuses on audit readiness and operational excellence for Medicare and Medicaid plans.

BluePeak is a leading national healthcare consultancy that focuses on government programs including Medicare Parts C and D, Medicaid, and Exchanges. We assist health plans, pharmacy benefit management (PBM) companies allied health companies and pharmaceutical manufacturers with regulatory, operational and compliance issues. BluePeak can analyze an organization’s processes and provide practical solutions, operational best practices and training to meet Medicare and other government program standards in all key areas.

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One of the most important activities that you can perform to get ready for CMS audits is practice universe pulls and mock CMS audits. BluePeak can assist you with preparation of universes, training of staff to present during the CMS audits and provide subject matter expertise in each of the CMS audit areas. We employ former CMS auditors so that we can execute a mock audit just as CMS will perform the audit. The report will contain information that will allow you to understand exactly where the issues lie and will give you actionable tasks that will allow you to remediate BEFORE CMS identifies the issues.

BluePeak understands the specialty market of All-Inclusive Care for the Elderly (PACE) plans and the importance of delivering of health care services to participants enrolled in PACE Organization with remaining compliant with CMS regulatory requirements associated with access to services, drugs, and other protections. Since CMS has increased its focus on audits of PACE plans, we anticipate the growing regulatory scrutiny that some PACE plans are facing–scrutiny and even receiving sanctions and civil money penalties (CMPs) for non-compliance. PACE audits evaluate the delivery of health care services provided to participants enrolled in PACE Organizations. It is critical for plans to have compliant and effective procedures in place to improve the efficiency and effectiveness of the audit process.

BluePeak assists PACE Plans with Quality Review, PACE Audit Protocols, Part D regulatory guidance and PDE/DIR support, Audit Process and Case Review preparations.

BluePeak is a leading national healthcare consultancy that focuses on government programs including Medicare Parts C and D, Medicaid, and Exchanges. We assist health plans, pharmacy benefit management (PBM) companies allied health companies and pharmaceutical manufacturers with regulatory, operational and compliance issues. BluePeak can analyze an organization’s processes and provide practical solutions, operational best practices and training to meet Medicare and other government program standards in all key areas.

The largest segment of our business is focused on health plans and assisting you with compliance, operations and interim staffing solutions. We are a leading Independent Validation Audit (IVA) vendor and have conducted over 150 mock Centers for Medicare and Medicaid Services (CMS) program audits and onsite support projects for clients undergoing actual CMS program audits.

A large segment of our business is focused on pharmacy benefit management (PBM) companies and assisting you with compliance, operations and interim staffing solutions. We have extensive experience in the PBM world, both on the clinical and operational side, with many operations experts and both founders of BluePeak being from the PBM industry.

BluePeak’s value to pharma stems from our extensive knowledge of the health plan, PBM and employer client marketplaces since we deal with them daily. We have in-depth experience with CMS policy and operational issues, and experience with many of the current PDPs and MAPDs.

BluePeak supports allied health companies in their efforts to provide compliant and effective products and services to health plans and Pharmacy Benefit Managers (PBMs). Applying insight gained from working with these industries, we provide clinical and regulatory subject matter expertise.

BluePeak is familiar with the nuances between states and their administration of the Medicaid program. We are able to provide many of our Medicare services, such as mock audit and audit support, marketing material review, operational assessments, and others, to our Medicaid clients.

BluePeak understands the importance of formulary management in driving clinical and financial outcomes. Our multi-disciplinary team can design and manage formulary solutions that align with your organization’s unique goals.

“BluePeak asked all the right questions to help us effectively prepare for our CMS Program Audit tracer review sessions.  In fact, after BluePeak’s pivotal guidance on how to strengthen our tracer summaries and how to think through the way in which to best answer the tough questions we might be asked by CMS, we ultimately had no findings during the CPE portion of our CMS Program Audit (even on the tracer summary we were most concerned about).  BluePeak’s CMS Program Audit support prep was invaluable to helping us thoroughly prepare, present with confidence, and drive our positive outcome.”

Medicare Compliance Officer, Fortune 50 Company

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Experienced Medicare staff: Ready when you are!

BluePeak knows how difficult it can be for Medicare Advantage plans and TPAs to find knowledgeable resources with experience in Medicare, especially when demands increase sharply given the Medicare annual cycle. BluePeak maintains a wide variety of experienced Medicare personnel to help you with seasonal projects, operational backlogs, compliance monitoring, remediation activities, and more.

Examples of projects that BluePeak has assisted plans in 2022 include:

  • Clinical chart review by licensed clinicians
  • Call center oversight, including listening to calls for accurate classification and calibration
  • Operational support to resolve grievance backlogs and provider directory compliance
  • Pharmacy support to resolve coverage determination backlogs
  • Program area specific operational and administrative responses to a corrective action (initiated internally or externally)
  • Compliance resources to support compliance program initiatives

Whether you need one resource or many, BluePeak can quickly staff any project, train resources, track results, and deliver success.

Contact us today!