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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.

Get the latest news and regulatory updates through our quarterly newsletter, BluePeak Bulletin, and our BluePeak News Alerts. Subscribe today to get these BluePeak publications directly to your inbox.

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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…

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…

What should plans do when COVID-19 impacts provider response times to standard and expedited appeals?

| COVID19 | No Comments
Plans have speculated that CMS might relax  the standard and expedited Appeals timeframes to allow more time for prescribers to respond since a large portion of prescriber’s offices are on…

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…

What Risk Does the new TERM Table Really Pose?

| Audits, Medicare, Part D, Spring 2024, Utilization Management | No Comments
Have you heard about the new table initially required in the CMS Utilization Management (UM)-Focused audits? Also, known as “Table 7”, Plans need to ensure an ability to report accurate…
moving clock

Decreased HSD Tables Application Requirement Now Leads to CMS Network Adequacy Review Later

| CMS, HPMS, Medicare, Uncategorized | No Comments
Decreased HSD Tables Application Requirement Now Leads to CMS Network Adequacy Review Later Part C applications may have decreased requirements for the submission of a key management staff organizational chart…

Is Your Opioid Program Compliant?

| CARA, CDAG, FA, Opioids, Part D | No Comments
In 2019, Medicare introduced new policies for opioid prescriptions in the Medicare Part D prescription drug program to encourage pharmacies, prescribers, and Medicare drug plans to work together with the…

Medicare AEP is over and 2021 is right around the corner.

| AEP | No Comments
While compliance is a year-round expectation of the Centers for Medicare and Medicaid Services (CMS), plans are under even greater scrutiny by CMS and members alike at the beginning of…

Consultant Corner: Inflation Reduction Act Implementation Best Practices and Planning for the Future

| Consultant Corner, IRA | No Comments
Jeff Baker, is a BluePeak Senior Health Plan Services Consultant. On August 16th, the Inflation Reduction Act of 2022 (IRA) was signed into law.  The text of the bill is…

Big Changes Ahead for Group Health Plans and Individual Health Plans

| Legal, Summaries | No Comments
The following are summaries of Rules that contain big changes for group health plans and individual health plans. SummaryInterim Final Rule with Comment Period Requirements Related to Surprise Billing; Part…

BluePeak Service Spotlight: HIPAA Program Review

| HIPAA, OCR | No Comments
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…

Using Interim Staffing to bring Appeals and Grievances Timeliness into Compliance–A Case Study

| Compliance, IRE, MA, MA-PD, Part D, PBM | No Comments
Sometimes, life happens. Turnover, volume increases, changing guidance, system changes or audit issues that require remediation all can create situations where a Plan or PBM needs expert resources fast.  And…

Annual Testing More Important than Ever

| CMS, FA | No Comments
The most effective way for any Plan to mitigate any compliance risks for the new plan year is to strategize a process to validate the accuracy of the formulary and…

Top Three Things Plans Need to Know to Manage and Improve Star Ratings

| Call Letter, CMS, Medicare, Part C, Part D | No Comments
The release of the 2019 Call Letter, which allows plans to include quality improvement and member intervention costs in their bid, signals the Centers for Medicare and Medicaid Services’ (CMS’)…

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)…

Avoiding a Perfect Storm-Proactive Testing and Claims Oversight is Key

| Compliance | No Comments
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…

Special Supplemental Benefits for the Chronically Ill: 2025 Proposed Rule Impacts to Consider

| CMS, December 2023, HHS, SSBCI | No Comments
Believe it or not, it is already time to start thinking about plan benefits for contract year 2025. Plan sponsors continue to look for ways to grow membership, modify benefit…

Calling All SNP Plans

| News Alert | No Comments
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…

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…

BluePeak Service Spotlight: Mock Audits with UMS and Call Log Reviews

| Call Log Review, CMS, UMS | No Comments
BluePeak has conducted over 150 CMS mock audits and onsite support projects for clients undergoing actual CMS program audits. We also offer mock audit breakouts, such as our Universe Monitoring…

Covid-19, CMS-4190-F, and Stars: Impacts During Uncertain Times-June 2020

| Case Studies, COVID19, Star Ratings | No Comments
Background On April 6, 2020, the Centers for Medicare & Medicaid Services (CMS) issued Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency (CMS-1744-IFC) as an interim…

Medicare Communications Marketing Guidelines: A Primary Topic at the CMS Fall Conference

| CMS, EOC, HPMS, Marketing, MCMG, Medicare | No Comments
BluePeak Highlights the Changes to MCMG Requirements The Centers for Medicare & Medicaid Services (CMS) 2018 Medicare & Prescription Drug Plan Fall Conference and Webcast kicked off on Thursday, September…

BluePeak Releases Summaries and Webinar Covering 2019 Call Letter

| Call Letter | No Comments
Bluepeak Subject Matter Experts (SME) have reviewed the 2019 Call Letter and created the following for your reference. 2019 Call Letter Summary Detailed overview of this year’s changes and what…

New Audit Protocols are Coming in 2021

| Audits, CDAG, CPE, FA, ODAG, SNP-MOC | No Comments
On December 6, 2019 CMS issued the HPMS Memo titled “Proposed Collection for New Medicare Part C and Part D Program Audit and Industry-Wide Part C Timeliness Monitoring Project (TMP)…

Initial Adoption of Indication-Based Formularies as a Formulary Management Tool

| CMS, Medicare, Part D | No Comments
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…

Changes Ahead for Plan Finder

| CMS, HPMS, MA | No Comments
During the CMS Spring Conference on May 1, 2019, CMS reviewed some of the revisions that are being made to Plan Finder. The redesigned Plan Finder will be used this…

Annual Enrollment Period (AEP) is Right Around the Corner-From Bid to Enrollment Processing

| AEP, Audits, Enrollment | No Comments
8 Tips to Ensure Your Plan is Ready After months of hard work and planning, everyone sighed with relief when bids and formularies were submitted earlier this month.  But, as…

Ensuring Record Retention Requirements with First-tier, Downstream and Related Entities (FDR’s).

| FDRs, Medicare, Part D, Uncategorized | No Comments
Many Medicare Plans may believe compliance with the ten-year record retention requirement is a slam-dunk.  However, plans are often tripped up in audits because their first-tier and downstream entities do…

CMS Releases 2022 Audit Protocols

| Audits, CDAG, CMS, ODAG, Part C, Part D | No Comments
With the 2021 Program Audit in full swing, CMS released the Program Audit Protocols for 2022 on May 26, 2021.    The 2022 protocols are very similar to what was previously…

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,…

BluePeak Podcast: Initial Thoughts on CMS 2018 Spring Conference

| Podcast | No Comments
Tune into BluePeak’s newest podcast, to hear Principal Babette Edgar and Senior Consultant Susan Herman discuss their initial thoughts on last week’s CMS 2018 Medicare Advantage & Prescription Drug Plan Spring…
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