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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.
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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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The Centers for Medicare & Medicaid Services (CMS) released an HPMS memo on August 20, 2019 providing an overview of the upcoming changes to program audits through 2021. These changes…
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…
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…
As we are begin the last quarter of 2021, Plans are thinking about readiness for January 1st. Below are just a couple of the areas that BluePeak suggests plans look…
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…
Recent 1/3 Financial Audits have focused on the accuracy of billing of medications while a member is in a skilled nursing facility (SNF). Most drugs administered during an acute stay in…
As plans prepare their drug management programs (DMPs) for CY2021 and beyond, there are several opioid provisions that must be implemented if this proposed rule (CMS-4190-P) is finalized. Below is…
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,…
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…
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…
While CMS has been conducting audits for many years via webinar, the new reality is that many of the Plans being audited this season may have workforce at home. Following…
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…
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…
Lisa B. Barker MBA, BSN, RN, CCM is a Senior Consultant, Part C Lead with BluePeak Advisors, a division of Gallagher Benefit Services, Inc. “See One, Do One, Teach One”…
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…
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…
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…
CMS released several interim and final rules in the past month. As the new year starts and there is a change in administration, the pace of new guidance releases is…
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)…
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…
The most effective way for any plan to avoid member disruption and compliance risks for the new plan year is to establish a process to validate the accuracy of the…
Case Study During the course of a Medicare Program Audit the plan struggled with being able to generate accurate and compliant universes in a timely manner. The plan had experienced…
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…
On November 2, 2020, CMS released the results of the CY2020 Monitoring of Posted Comprehensive Formularies or their Posted versus Approved (PvA) analysis. For the CY2020 analysis, CMS announced that…
From February to August, the Centers for Medicare & Medicaid Services (CMS) conducted the second round of online provider directory reviews of 64 Medicare Advantage Organizations (MAOs). CMS reviewed online…
The Organizational Determination (OD) and Coverage Determination (CD) process can be a source of frustration for members, prescribers and plans. The updates to Chapter 13 and 18 highlight the expectation…
COVID-19 is having a dramatic impact on our lives, businesses and health care system. We understand that information and circumstances are changing rapidly and that many of your team members are…
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)…