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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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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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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 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…
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…
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…
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…
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…
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 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…
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…
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,…
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…
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…
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,…
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…
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…
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…
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…
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…
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)…
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…
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 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…
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…
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…
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…
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…
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…
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…
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…