Part D Audit Insights for CY2024: Key Takeaways
As the CY2024 audit season wraps up, the Centers for Medicare and Medicaid Services (CMS) has been publishing both draft and final reports for those selected for program audits. We…
BluePeak Advisors, a division of Gallagher Benefit Services, Inc., 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. Our consultants are 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. Our team has experience and expertise to service our clients in every aspect of Commercial and Medicare programs. BluePeak’s focus lies in PBM and Medicare Advantage (MA) and Medicare Advantage Prescription Drug Plan (MA-PD) health plan operations, Medicare compliance consulting, STAR rating improvements, CMS advocacy and support, pharmaceutical manufacturer marketing, and payer strategies for reimbursement. BluePeak also has expertise in Medicare fraud prevention, operational and clinical program strategies, data analytics, and Medicaid managed care, Special Needs Plans (SNP), Program of All-Inclusive Care for the Elderly (PACE) Plan audit and compliance. BluePeak’s unparalleled operational and audit experience positions us to solve any issue and ensure operational success and audit readiness.
BluePeak leads the nation in healthcare compliance consulting 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.
Medicare Prescription Payment Program (M3P)
Beginning in 2025, the prescription drug law, known as the Inflation Reduction Act, requires all Medicare prescription drug plans (Medicare Part D plans) — including both standalone Medicare prescription drug plans and Medicare Advantage plans with prescription drug coverage — to offer enrollees the option to pay out-of-pocket prescription drug costs in the form of capped monthly payments instead of all at once at the pharmacy, otherwise known as the Medicare Prescription Payment Program or M3P.
BluePeak can support the implementation of M3P at every stage of the process including Enrollment, Marketing, Billing, Claims Processing, Planning for questions and complaints, and Termination.
Federally Facilitated Exchange (FFE) Mock Audits & Audit Support
BluePeak helps plans prepare for audits of their FFE Plan. BluePeak’s mock audits are conducted in a manner which simulates a real audit from The Centers for Medicare and Medicaid Services (CMS) and The Center for Consumer Information and Insurance Oversight (CCIIO). The mock audit will include a formal audit announcement, set submission timeframes, an entrance and exit conference, as well as documentation review and case sampling of HICS Casework, Enrollments, Terminations and Renewal-Discontinuation Letters and more.
BluePeak also supports Qualified Health Plans (QHPs) that have received their FFE audit notice with end-to-end audit support or customized support as needed. Click the link to learn more about how plans can optimize FFE Compliance with BluePeak’s expert audit insight.
Program of All-Inclusive Care for the Elderly (PACE)
BluePeak understands the specialty market of All-Inclusive Care for the Elderly (PACE) Organizations 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 Organizations, we anticipate the growing regulatory scrutiny that some PACE Organizations 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 organizations to have compliant and effective procedures in place to improve the efficiency and effectiveness of the audit process.
As your PACE and Medicare compliance consulting company, BluePeak assists PACE Organizations with Quality Review, PACE Audit Protocols, Part D regulatory guidance and PDE/DIR support, Audit Process and Case Review preparations.
Medicare Advantage (MA) Mock Audits
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 provide you Medicare compliance solutions and 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.
Medicare Sales & Marketing Services
BluePeak’s comprehensive Medicare Annual Enrollment Period (AEP) Support from pre-AEP, during and post AEP to ensure you are achieving Medicare regulatory compliance, including:
- Sales & Marketing Oversight Assessments
- Bid – PBP Quality Reviews
- Member Material Development and/or Review
- Broker Assessments
- Sales Training Development Support
- AEP Agent Secret Shopping Reviews
Operations
BluePeak Advisors can provide health plans and pharmacy benefit managers assistance with Part C and D Medicare operations remediation and efficiencies.
Compliance
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.
Strategy
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.
Solutions by Market
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.
Health Plans
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.
Pharmacy Benefit Management
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.
Pharmaceutical Manufacturers
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.
Allied Healthcare Companies
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.
Medicaid
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.
Formulary Development and Support
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 Bulletin
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Should Off-cycle MOC Submission Be a Priority, RIGHT NOW?
Should Off-cycle MOC Submission Be a Priority, RIGHT NOW?
December 1, 2024, signals closure of the 2024 the National Committee for Quality Assurance (NCQA) Model of Care (MOC) Off-Cycle submission window, but there is still time to update if you…
2024 Audit Trends: Special Needs Plans
2024 Audit Trends: Special Needs Plans
The 2024 the Centers for Medicare and Medicaid Services (CMS) audit season brought a diverse array of trends for Special Needs Plans (SNPs) yet one consistent and notable emphasis prevailed:…