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BluePeak Bulletin

Since its inception, BluePeak has been committed to making the complicated world of government-sponsored healthcare programs easier to navigate. BluePeak employees pride themselves on delivering outstanding consulting services to our varied clients through our motto of Knowledge, Experience, and Trust. Read through our past articles from our quarterly newsletters and news alerts.

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As we navigate the evolving landscape of healthcare regulations, BluePeak is dedicated to helping you manage these complexities and ensure compliance with all requirements. We are preparing a special edition to deliver the latest updates and insights directly to your inbox. Subscribe today to stay informed. For more information on how BluePeak can assist you, please email us at info@bluepeak.com.

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Proposed Rule Re: Medicare Program

| CMS, PACE, Part C, Part D, Winter 2024 | No Comments
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…

Risk-Adjustment Data Validation Readiness: Key Strategies for Compliance

| CMS, HCC, OIG, Winter 2024 | No Comments
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…

Navigating the Future of Utilization Management Requirements

| Part D, Utilization Management, Winter 2024 | No Comments
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…

Medicare Prescription Payment Plan – Are you ready for it?

| IRA, MPPP, Winter 2024 | No Comments
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)…

Part D Audit Insights for CY2024: Key Takeaways

| Fall 2024, Part D | No Comments
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…

Should Off-cycle MOC Submission Be a Priority, RIGHT NOW?

| Fall 2024, MOC, NCQA | No Comments
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

| Audits, Fall 2024 | No Comments
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:…

2025 Plan Readiness: Are You Prepared?

| CMS, Fall 2024, IVR, M3P, Member Materials, Part C, Part D, SSBCI | No Comments
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…

Upcoming IRA Changes for 2025: Key Considerations for Year End Testing

| Audits, CMS, Summer 2024 | No Comments
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…

Understanding Dual-Eligible Special Needs Plans (D-SNPs): Your essential guide to types of D-SNPs and the impact of MMPs Sunsetting

| CMS, D-SNP, MMP, Summer 2024 | No Comments
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…

Consultant Corner: Updates to the Plan Communication User Guide That Require Attention

| Audits, Consultant Corner, Summer 2024 | No Comments
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…

2024 Utilization Management (UM)- Focused Audits: Lessons Learned

| Summer 2024, Utilization Management | No Comments
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…

2023 CMS Program Audit Trends and Key Details: What We Know So Far

| CDAG, CPE, FA, June 2023, ODAG, SNP-MOC | No Comments
On November 30, 2022, the Centers for Medicare and Medicaid Services (CMS) Medicare Parts C and D Oversight and Enforcement Group (MOEG) announced the 2023 program audit updates.  CMS is…

Part D Operational Implications of the Inflation Reduction Act (IRA) of 2022

| IRA, November 2022 | No Comments
On August 16th, the Inflation Reduction Act of 2022 (IRA) was signed into law.  The text of the bill is located here and includes changes that, among other things, would…

2019 Program Audits Reflect Continued Improvement

| Audits | No Comments
Reprinted with AIS Health permission from the October 1, 2020, issue of RADAR on Medicare Advantage CMS’s latest overview of program audits showed continued improvement among Medicare Advantage and Part…

Is Your Part D Stars Program Ready to Ring in the New Year?

| December 2023, Opioids, Part D | No Comments
On April 12, 2023, Centers for Medicare & Medicaid Services (CMS) published the 2024 Final Rule that postponed moving the three polypharmacy measures (Concurrent Use of Opioids and Benzodiazepines, Polypharmacy…

Upcoming IRA Changes for 2025: Key Considerations for Year End Testing

| Audits, CMS, Summer 2024 | No Comments
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…
prescription drugs

PDE SELF AUDITS in 2018

| CMS, Part C, Part D, PDE | No Comments
Throughout 2017, CMS continued its vigilance over drug claim payments by conducting Prescription Drug Event (PDE) Self-Audits. The drugs under audit in 2018 may change, but CMS has not yet…

Highlights of the Final Rule

| CMS, Medicare, PACE | No Comments
Contract Year 2022 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicaid Program, Medicare Cost Plan Program, and Programs of All-Inclusive Care for the…

CMS Increases Part D Self Audits Targeting Payment and Benefit Inaccuracies from PDE Data

| Audits, Claims, CMS, COVID19, ESRD, MME, Part A, Part B, Part D | No Comments
CMS Program Audit season is over and as anticipated, the volume of Program Audits increased substantially in 2021 over prior years​. In addition, CMS introduced Part D self-audits which also…

OIG finds MAOs Inappropriately Denying Requests for PA and Payment, CMS agrees to Issue Stricter Guidance and update Audit Protocols and Auditor Training

| CMS | No Comments
In late April, the U.S. Department of Health and Human Services Office of Inspector General (OIG) released their detailed findings concerning inappropriate denials of prior authorization (PA) requests and payment…

Provider Directory Accuracy Monitoring and Use of the National Plan & Provider Enumeration System (NPPES)

| CMS, Part C, Part D | No Comments
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,…

NEWS ALERT – 12/27/2022

| News Alert | No Comments
BluePeak’s releases index on the entire proposed rule contents December 27, 2022, CMS published proposed rule CMS FRDOC 001 regarding Medicare Program; Contract Year 2024 Policy and Technical Changes to…

Summary of CMS Changes to Enrollment Requirements for CY2021

| AEP, Enrollment | No Comments
Plans may have noticed that CMS has been busy this season making changes to certain Enrollment policies, materials, and software releases to keep up with the changing environment of today…

Rethinking Your Risk Adjustment “Risk Management” Program

| FDR, OIG | No Comments
Risk adjustment is expected to receive additional focus and attention from federal regulators in the near term.  Political and administrative changes frequently shift the focus and attention of oversight agencies,…

2024 Final Rule Changes: Impacts on Utilization Management Tools and Proposed Changes for 2025.

| CMS, December 2023, Utilization Management | No Comments
The Final Rule 2024 is one of the most substantive in recent years, with clarifications, codifications to existing rules and new requirements!  Plans need to be well prepared this year…

Past Performance, Encounters and Misclassifications, Oh My!

| Audits, CMS, Compliance, Part C, Part D, Past Performance, Uncategorized | No Comments
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…

Should Off-cycle MOC Submission Be a Priority, RIGHT NOW?

| Fall 2024, MOC, NCQA | No Comments
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…

Medicare Advantage and Prescription Drug Plan Appeals Guidance– Are You Ready?

| HPMS, Medicare, PDBM | No Comments
Chapter 13 of the Medicare Managed Care Manual (MMCM) and Chapter 18 of the Prescription Drug Benefit Manual (PDBM) have been consolidated into one chapter. CMS announced the release of…

Service Spotlight: End-to-End Part C Claims Testing

| Service Spotlight | No Comments
Now that bids have been submitted, it is time to start thinking about 2022 compliance and operations. One of the best ways to prepare for audit success and happy members…

Medicare Prescription Payment Plan – Are you ready for it?

| IRA, MPPP, Winter 2024 | No Comments
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)…

Benefits of a Compliance Program Effectiveness Audit– Going Beyond Just Meeting the Requirement

| Audits, CMS, CPE | No Comments
CMS guidance requires Medicare Advantage Plans to have an independent audit of their compliance program’s effectiveness each year.  Given competing priorities, it may be tempting to conduct a limited or…

Cost of Non-Compliance

| CMPs, CMS, Medicare, Part C, Part D | No Comments
Did you know... Forty-six percent of sponsors subject to a 2016 Program Audit received a Civil Money Penalty (CMP) for violations of Medicare Parts C and D requirements found by…

Two Rules With Potential Part D Rebate Access Impact

| CMS, Medicare, Part D | No Comments
Two rules have the potential to impact how Part D price concessions and pharmaceutical rebates are managed and how these changes, when implemented, will subsequently impact a Part D sponsor’s…

CMS Discusses Draft 2019 Audit Protocols and More at Conferences

| Audits, CMS, Uncategorized | No Comments
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…

‘Tis ALWAYS the season….for rejected claims analysis.

| CMS, PBM | No Comments
As year-end approaches, most plans are conducting claims testing to ensure that formularies and benefits are administered correctly on January 1 and beyond.  Plans and PBMs alike that have experienced…

CMS Updates Definition of Marketing, Reduces Required Hard Copy Member Materials

| CMS, Marketing, MCMG, Medicare | No Comments
The Centers for Medicare and Medicaid Services (CMS) typically issues a draft version of the Medicare Marketing Guidelines (MMG) early in the year for comment before releasing the final version…

Is Your Plan Ready for the New Year?

| CMS, MBI, Medicare, Open Enrollment, Part D | No Comments
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…

Risks in Misclassifying First Tier, Downstream, and Related Entities (FDRs)

| MA, MCMG, Medicare, November 2022 | No Comments
There are a number of criteria outlining the oversight of First Tier, Downstream and Related Entities for Medicare Advantage Organizations.  Chapters 21 / 9 and 11 of the Medicare Managed…

It is Always a Good Time to Think About Star Ratings

| HEDIS, MPF, Star Ratings | No Comments
As you checked your plan data that will be displayed on Medicare Plan Finder (MPF) for accuracy during the recent second plan preview, were you happy with your Star Ratings?…

The 2019 CMS Program Audit Season is Upon Us!

| Audits, CDAG, CMS, CPE, FA, ODAG, SARAG, SNP-MOC | No Comments
CMS started issuing audit letters in March and will continue doing so through July. If you haven't already received an audit notice, what are you doing to prepare? 2019 starts…

Consultant Corner: Importance of Accurate Member Marketing Materials

| Consultant Corner, June 2023 | No Comments
Jill Pepe is a BluePeak Senior Consultant and Marketing Material Review Lead The Centers for Medicare and Medicaid Services (CMS) Annual bid process and timeline is one constant plan Sponsors…