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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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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…
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…
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…
On December 27, 2022, the Centers for Medicare & Medicaid Services (CMS) published proposed rule (CMS_FRDOC_0001-3474) in the Federal Register. If finalized, this proposed rule would revise the Medicare Advantage…
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…
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,…
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…
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…
History and Methodology The transition monitoring program analysis (TMPA) has been in effect since 2012 and will likely be a staple in the Part D program for several years to…
NEW! Beginning January 1, 2022, plans must send a written notice of dismissal for Part C OD and reconsideration requests as well as for Part D CD and redetermination requests…
Unapproved Drugs Initiative Terminated On November 20, 2020 The Department of Health and Human Services terminated the Unapproved Drugs Initiative. The 2006 Unapproved Drug Initiative requires manufacturers to submit drugs…
What is the Issue?1 In August 2019, the Department of Health and Human Services Office of Inspector General (OIG) released a report entitled, Medicare Part D is Still Paying Millions…
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…
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…
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 May 25, 2021, the Department of Health and Human Services (HHS) announced that it would again interpret and enforce the Section 1557 of the Affordable Care Act (Section 1557)…
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 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…
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…
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…
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…
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…
On May 23, 2019, the Centers for Medicare & Medicaid Services (CMS) published a final rule (CMS-4180-F) which adopted new processing timeframe requirements for preservice organization determinations and plan reconsiderations…
The last quarter of 2020 will likely be the most significant and the most challenging testing season plans have experienced. Unfortunately, there may be a perfect storm brewing that is…
Annual risk assessments and associated monitoring and auditing work plans are not only required, but also help to ensure your compliance program is efficiently and effectively monitoring and auditing business…
CMS continues to move PACE Organizations into alignment with Medicare Advantage plans, and use of past performance to inform request for new or expanded PACE programs is no exception. While…
Participation is expected to be strong in the Part D Senior Savings Model launch on 1/1/21 with 1,750 plans across 88 sponsors and 3 manufacturers participating in the program. Participating…
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…
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,…
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…