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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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In the evolving landscape of healthcare coverage, ensuring parity between mental health/substance use disorder (MH/SUD) and medical/surgical (Med/Surg) services is crucial. The Mental Health Parity and Addiction Equity Act (MHPAEA)…
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…
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…
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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…
Background On September 14, 2020 CMS released The Advance Notice of Methodological Changes for Calendar Year (CY) 2022 for Medicare Advantage (MA) Capitation Rates and Part C and Part D…
CMS has announced a 30-day comment period for the proposed collection entitled “The PACE Organization (PO) Monitoring and Audit Process” (CMS-10630; OMB control number: 0938–1327). This notice was published on…
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…
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…
CMS Program Audit season is over and as anticipated, the volume of Program Audits in 2022 increased substantially over prior years. From a Part D perspective, audits have touched almost…
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)…
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…
On March 9, 2020, the Centers for Medicare & Medicaid Services (CMS) released the final rule (CMS-9115-F) regarding Interoperability and Patient Access. While CMS issued a fact sheet regarding this rule, this rule…
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: BluePeak discusses the impact…
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…
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…
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…
As Plans Continue to Struggle with the Same Common Conditions, CMS Makes Few Changes from the 2017 to 2018 Audit Protocols As the Centers for Medicare and Medicaid Services (CMS)…
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…
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…
If your Model of Care (MOC) was written before 2025, it’s already outdated. With the release of the Centers for Medicare and Medicaid Services’ (CMS) draft MOC model documents, the…
Independent Review Entity (IRE) Transparency Initiative Plans are continuously looking for data to better understand their appeals outcome. The IRE transparency initiative provides plans with several more tools. During the…
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…
Bids were turned in the first Monday in June and now it is time to implement those benefits, plan designs and formularies that your organization has been hard at work…
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…
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…
Bid approved – check. Member materials sent to printer – check. What other items should be on your radar over the next few months? The Centers for Medicare and Medicaid…
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…
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:…
In June, CMS issued updated technical specifications for CY 2022 Medicare Part C and Part D reporting. BluePeak has summarized the key changes in the technical specifications below. BluePeak compared…
Beginning in the 2020 contract year (“CY2020”), the Centers for Medicare & Medicaid Services (“CMS”) will permit Part D sponsors to implement indication-based formulary designs that tailor formulary coverage of…
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…
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…