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 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 By the Numbers
BluePeak has worked with most PBMs and
completed by BluePeak since 2016, when CMS formalized the Independent Validation Audit (IVA) process.
Over the past 12 years, BluePeak has been successful in helping
onsite support projects
have been conducted since 2013 for clients undergoing actual CMS program audits.
Conducts Member Material Reviews:
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 550 mock Centers for Medicare and Medicaid Services (CMS) program audits and onsite support projects for clients undergoing actual CMS program audits. We have worked in various capacities with every sanctioned plan since 2010 and understand how to navigate the relationships with both the national and regional CMS offices.
BluePeak works health plans of all sizes including large national, Blues, regional and local plans with Medicare Advantage (MA), Medicare Advantage-Prescription Drug (MA-PD), Part D and Employer Group Waiver Plans (EGWPs). Support the following projects for health plans and so much more!
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.
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.
Medicare product strategy and development, vendor insourcing vs. outsourcing of products and solutions with RFP support.
More projects include Medicare and managed care market support, Marketing strategy and product planning services, Product reimbursement strategies, Strategic planning for all market segments, CMS policy interpretation, Contracting and customer strategies, CMS advocacy, Data analysis services, Advisory board moderation and development, White Papers
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. BluePeak understands the pressures of having many different health plans wanting different things from the PBM, as well as CMS actions that all hit at once, like the transition audits, and how hard that is to manage. The most common projects include but are not limited to:
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.
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.
Medicare product strategy and development, Medicare product pricing, claims processing strategies, insourcing vs. outsourcing of products and solutions.
BluePeak is familiar with the nuances between states and their administration of the Medicaid program. We have also observed the growing alignment between Medicaid, Medicare and private coverage plans, as a result of the Medicaid and Children’s Health Insurance Program (CHIP) Managed Care Final Rule and the Medicare-Medicaid Plans (MMPs). Timeframes and processes for member notices, coverage decisions, grievances, encounter data reporting, provider networks and directories, transition of care, quality rating systems, records retention, etc. will be consistent across the various managed care plans by 2021. As a result, 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 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. Program of All-Inclusive Care for the Elderly (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 Program of All-Inclusive Care for the Elderly (PACE) Plans with Quality Review, PACE Audit Protocols, PACE Audit Process and Case Review preparations.
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 to enhance the non-profit, legal, clinical, educational or commercial business operations of our allied health company clients.
BluePeak supports Allied Healthcare companies with 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.
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. We understand how they think and what decisions will likely be made. Coupled with our knowledge of the pharmaceutical industry, we can support you in your Medicare and managed care market and reimbursement strategies.
BluePeak supports pharmaceutical manufacture’s with the following:
- Formulary Management Strategies
- Pull-through Strategies
- Client Strategies and Issues Support
- Contracting Strategies and Support
- Interim Staffing
- CMS Advocacy and Planning
- HPMS Memos Service