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- April 17, 2025 | Information to Review Data Used for Medicare Part C and D Star Ratings and Display Measures
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Proposed Rule Re: Medicare Program; Contract Year 2026 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicare Cost Plan Program, and Programs of All-Inclusive…
Did you know that there are publicly accessible resources identifying highly scrutinized Hierarchical Condition Category (HCC) codes that may be problematic for your plan? Did you know there’s an annual…
As 2024 comes to a close, the Centers for Medicare & Medicaid Services (CMS) Utilization Management (UM) requirements remain as high priority, and 2025 brings with it new considerations for…
The Inflation Reduction Act (IRA) introduced several changes to the Medicare landscape. One of the biggest changes that impacts members and plans alike is the Medicare Prescription Payment Plan (MPPP)…
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…
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…
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:…
As you put the final touches on Plan Year 2025 implementation, it is crucial for Medicare plans to stay ahead of the game and be prepared for the changes that…
Since its passage, the Inflation Reduction Act (IRA) of 2022 has ushered in changes to the Medicare Part D benefit each contract year (CY) and 2025 is no different. Now…
In May of 2022, CMS finalized the rule that will sunset Medicare-Medicaid Plans (MMPs). This rule proposes that required states transition their MMP enrollees to integrated Medicare Advantage dual eligible…
Meryl Chick is a Consultant with BluePeak Advisors, a division of Gallagher Benefit Services, Inc. Are you monitoring the Batch Completion Status Summary (BCSS)? If the answer is no and…
The annual Centers for Medicare and Medicaid Services (CMS) Audit Season has been in full swing since the beginning of the year with a focus on Utilization Management. CMS is…
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While most people are singing Auld Lang Sine at midnight on January 1, those of us in the Medicare world are anxiously awaiting the first claims of the plan year…
Is your Special Needs Plan (SNP) due for a 2025 Model of Care (MOC) submission? With a due date of February 2024, we encourage you to not wait to review…
Many of the proposed audit protocol changes for both the 2020 and 2021 audit season included changes to universes. An incomplete and incorrect universe can add 1 point toward your…
Annual Notices of Changes (ANOC) shared with enrollees Evidence of Coverage (EOC) shared with enrollees Formulary shared with enrollees Pharmacy and Provider Directories shared with enrollees Medicare Communications Marketing Guidelines…
In August of 2018, CMS announced that Medicare Part D Sponsors have the option to use indication-based formularies starting January 1, 2020. Prior to this change, formulary medications were considered…
When an enrollee contacts the plan about a provider’s bill, it can be challenging to determine if the enrollee’s issue should be classified as an inquiry or processed under the…
In October, the National Health Care Anti-Fraud Association (NHCAA) held its annual training conference that spotlighted emerging fraud schemes. In addition to updates on the brace, genetic testing, and foot…
Beginning October 2022 and continuing throughout 2023, CMS, in conjunction with the Plan Program Integrity Medicare Drug Integrity Contract (PPI MEDIC), will initiate three National Audits, six Self-Audits and four…
COVID-19 is having a dramatic impact on our lives, businesses and health care system. We understand that information and circumstances are changing rapidly and that many of your team members are…
HIPAA Violations = Potential Civil Fines and Criminal Penalties How healthy is your HIPAA Program? BluePeak’s HIPAA Program Review can help you identify and correct privacy, security and breach policy and procedure issues that might leave…
On May 10, 2019, CMS published a final rule on Drug Pricing Transparency. The rule, effective July 9, 2019, requires direct-to-consumer television advertisements of prescription drugs and biological products payable…
The Centers for Medicare and Medicaid Services (CMS) requires, as part of the formulary submission process, each plan sponsor complete the Transition Policy Attestation through the formulary submission module in…
CMS Account Managers May Contact Plans to Assess New Medicare Card Project Readiness PDE Self-Audits Cost At Least One Plan Over $1 Million in Claims Reversals CMS to Conduct Provider…
CMS released several interim and final rules in the past month. As the new year starts and there is a change in administration, the pace of new guidance releases is…
During the 2017 audit season, BluePeak observed increased CMS increased scrutiny on plans and their First Tier, Downstream and Related Entities (FDRs), as well as repeated Common Conditions. With limited changes from…
On July 20, 2018, the Centers for Medicare & Medicaid Services (“CMS”) released the Medicare Communications and Marketing Guidelines (“MCMG”), replacing the Medicare Marketing Guidelines and all associated guidance in…
The 2021 PDE submission deadline is June 29, 2022. Plans must attest to the accuracy of their submitted PDE records prior to CMS’ financial reconciliation. The challenge is that many…
CMS denies applications due to Past Performance scores, encounter data volume is growing, and misclassification of appeals and grievances continues to be an issue. BluePeak tells you what you need…
On March 11, 2020 the CMS Part C and D User Call focused on Provider Directory accuracy and how the NPPES may support such accuracy. In case you missed it,…
In addition to CMS performing numerous program audits thus far in 2021, recent memos have denoted that CMS is moving forward with several self-audits for plans to consider. In April,…
CMS issued a Fraud Alert on COVID-19 schemes on March 23 and additional guidance was released via HPMS on April 1st. On April 16th, the National Health Care Fraud Anti-Fraud…
The Inflation Reduction Act (IRA) is poised to bring a significant transformation to the Medicare Part D benefit starting in 2025. This redesign will impact many stakeholders, including Part D…
On April 12, 2023, the Centers for Medicare & Medicaid Services (CMS) released the 2024 Final Rule in the Federal Register (2024 Final Rule). Among other provisions, the Final Rule…
Did you know that there are publicly accessible resources identifying highly scrutinized Hierarchical Condition Category (HCC) codes that may be problematic for your plan? Did you know there’s an annual…
Effective January 1, 2019, the Centers for Medicaid & Medicare Services (CMS) required plan sponsors to implement new opioid policies as part of the agency’s continued efforts to address the…
BluePeak Lists Top 5 Changes by Impact to Plan Sponsors Following a flurry of final and proposed rulemaking in April, the Centers for Medicare and Medicaid Services (CMS) discussed program…
Looking for more articles and insight from us? Head over to our LinkedIn page to discover more. Here are some of the recent articles posted there: Claim Accuracy is More…
The Facts are Sobering: CMPs may be the least expensive part of being non-compliant. CMS audits are on the rise, as are CMPs and sanctions. The average CMP is around…
In the ‘2022 Program Audit Process Overview’1 document, the Centers for Medicare & Medicaid Services (CMS) shared that they will send engagement letters to initiate routine audits beginning February 2022 through…
The most effective way for any plan to avoid member disruption and compliance risks for the new plan year is to establish a process to validate the accuracy of the…