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BluePeak News Alerts
- October 1, 2024 | OIG requests Medicare Part C Pre-service Universes for Care in Long-term Acute Care Hospitals, Skilled Nursing Facilities, Inpatient Rehabilitation Facilities
- August 1, 2024 | CMS released the Part D National Average Monthly Bid Amount and Other Part C & D Bid Information
- July 18, 2024 | CMS Releases Memo: ‘Submitting Other TrOOP Amount Information for 2023 Part D Payment Reconciliation of the Inflation Reduction Act Subsidy Amount (IRASA)’
- July 17, 2024 | CMS releases the highly anticipated Medicare Prescription Payment Plan: Final Part Two Guidance on Select Topics
- July 16, 2024 | Steward Health Care files for bankruptcy–Plans will need to assess impact on network adequacy
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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In the ‘2022 Program Audit Process Overview’1 document, the Centers for Medicare & Medicaid Services (CMS) shared that they will send engagement letters to initiate routine audits beginning February 2022 through…
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…
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…
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…
The Centers for Medicare & Medicaid Services (CMS) is now considering deficiencies found from one-third financial audits for potential enforcement actions, including Civil Money Penalties (CMPs), according to a memo…
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…
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)…
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…
There are several noteworthy regulatory changes that require action by Medicare Advantage and Part D Plans in 2021. 1. Provider-Facing Electronic Real-Time Benefit Tool (RTBT) CMS issued a final rule…
More Rigorous CMS Oversight and Audit Activity Ahead Audit notices are already hitting inboxes as CMS is kicking off a longer than usual Program Audit season this year (March through…
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)…
Whether deficiencies are discovered as part of a CMS program audit or a Timeliness Monitoring Project (TMP) review, issues with appeals and Independent Review (IRE) data can impact a plan’s Star Ratings…
New COVID-19 Related Audit Considerations In addition to all of the other usual audit concerns, Plan Sponsors should also be prepared for CMS to scrutinize all things COVID-19 related. As…
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…
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…
The 2019 plan year has not commenced, yet plans are already developing formulary strategies for 2020. Indication-based formulary designs will add a new twist for plan sponsors to consider as…
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…
From 2016-2017, audit scores were lower in all areas, except Compliance Program Effectiveness (CPE); Civil Money Penalties (CMPs) were significantly reduced; and most Common Conditions were repeated, according to the…
From July 16-18th over 100 investigative minds met at the annual CMS Fraud Conference in Miami, Florida to talk about current fraud schemes, emerging schemes, data analytics and how to…
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…
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…
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…
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…
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…
On February 5, 2020, the Centers for Medicare & Medicaid Services (CMS) announced it will not be publishing a Call Letter for 2021. Rather, CMS is codifying guidance typically published…
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…
CMS issued a Fraud Alert on COVID-19 schemes on March 23 and additional guidance was released via HPMS on April 1st. On April 16th, the National Health Care Fraud Anti-Fraud…
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…