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- April 17, 2025 | Information to Review Data Used for Medicare Part C and D Star Ratings and Display Measures
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.
In This Issue | Spring 2025
- Understanding Non-Quantitative Treatment Limitations (NQTLs) and How BluePeak Advisors Can Help
- Medicare Part D Redesign: Navigating the Changes in 2025
Discover Previous Issues
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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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…
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…
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…
The Department of Health and Human Services (HHS) and Centers for Medicare & Medicaid Services (CMS) have published several new proposed and final rules on various topics, ranging from prescription…
On 2/28/2020, CMS released the Civil Money Penalty (CMP) Enforcement Actions for 2019 Program Audits. Contract year 2019 was the first year of this audit cycle and we have incorporated…
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…
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…
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…
Hot Topic MTM has become a popular topic with CMS not only at their Spring conference but also as a new pilot for their Program Audits. CMS is placing more…
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: Audit Tip #3-- It’s…
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…
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…
One of the biggest Part D changes revealed in the 2019 Call Letter was the closure of the Coverage Discount Gap Program a year earlier than scheduled. As a result,…
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…
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…
BluePeak's Summary on COVID-19 Gallagher Special Olympic partnership COVID-19 Medicare Fact Sheet 10 Things Plan need to know about the Proposed Rule Kelly MaKay, RPh, MBA Senior Health Plan Services…
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 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…
To assist Medicare Part D sponsors with monitoring efforts and potentially avoid overutilization of opioids in the elderly Medicare population, CMS has deployed numerous strategies over the past several years…
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 October 26, President Donald Trump declared the nation’s opioid epidemic a public health emergency. The opioid epidemic is the deadliest drug epidemic in American history. Deaths from opioid overdose…
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…
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…
The Centers for Medicare & Medicaid Services (CMS) recently released a proposed rule titled “Patient Protection and Affordable Care Act; Updating Payment Parameters, Section 1332 Waiver Implementing Regulations, and Improving…
Member materials are an important part of the Medicare member experience with a plan. Each year as Plan Sponsors finalize their product bid filing, CMS releases the upcoming plan year…
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 April 8, 2022, CMS released the updates to the standard Civil Money Penalty (CMP) amounts that will be used for the next three years beginning with plan year 2022. …
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…