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BluePeak Bulletin

Since its inception, BluePeak has been committed to making the complicated world of government-sponsored healthcare programs easier to navigate. BluePeak employees pride themselves on delivering outstanding consulting services to our varied clients through our motto of Knowledge, Experience, and Trust. Read through our past articles from our quarterly newsletters and news alerts.

Get the latest news and regulatory updates through our quarterly newsletter, BluePeak Bulletin, and our BluePeak News Alerts. Subscribe today to get these BluePeak publications directly to your inbox.

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The Centers for Medicare & Medicaid Services: 2024 Readiness Checklist for Medicare Advantage Organizations, Prescription Drug Plans

| CMS, December 2023 | No Comments
The Centers for Medicare & Medicaid Services (CMS) released the CY2024 Medicare Parts C and D Readiness Checklist on October 13, 2023. Although this is a busy time of year,…

Special Supplemental Benefits for the Chronically Ill: 2025 Proposed Rule Impacts to Consider

| CMS, December 2023, HHS, SSBCI | No Comments
Believe it or not, it is already time to start thinking about plan benefits for contract year 2025. Plan sponsors continue to look for ways to grow membership, modify benefit…

Is Your Part D Stars Program Ready to Ring in the New Year?

| December 2023, Opioids, Part D | No Comments
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…

Inflation Reduction Act (IRA): 2024 Summary of Changes and Oversight Considerations

| CMS, December 2023, IRA | No Comments
The Centers for Medicare & Medicaid Services (CMS) has released significant guidance to support the Inflation Reduction Act (IRA) provisions that impacts Medicare enrollees, health plans, pharmacy benefit managers (PBM)…

Consultant Corner: Strategic Planning: Using the Notice of Intent to Apply timing to trigger potential opportunities with your leadership and Board of Directors

| AEP, September 2023 | No Comments
Wendy Edwards, MPA, CHC, CHPC, is Director of Internal Operations at BluePeak Advisors, a division of Gallagher Benefit Services, Inc. Preparing for 2025 may not be at the top -of-mind…

Classifying An Enrollee Billing Complaint as a Grievance, Coverage Request, or Both?

| Claims, September 2023 | No Comments
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…

Changes to CMS Requirements for Translation and Alternate Formats

| FDR, MA, Part D, September 2023 | No Comments
To ensure effective communication and meaningful access, Medicare Advantage (MA) and Prescription Drug Plans (PDPs) have been obligated to follow various, occasionally interconnected directives for translating member documents into different…

2024 National Average Monthly Bid Amount Impact

| PBM, September 2023 | No Comments
On July 31, 2023, Centers for Medicare & Medicaid Services (CMS) released the National Average Monthly Bid Amount (NAMBA) for contract year (CY) 2024.  For 2024, the national average bid…

Third Party Marketing Organization (TPMO) Requirements – Not just a Sales Department Responsibility

| June 2023, TPMO | No Comments
If it seems as though the Centers for Medicare and Medicaid Services (CMS) has increased its focus, oversight and scrutiny on the marketing practices of some agents and brokers for…

Consultant Corner: Importance of Accurate Member Marketing Materials

| Consultant Corner, June 2023 | No Comments
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…

Inflation Reduction Act (IRA) Drug Rebate Program and Drug Price Negotiation

| IRA, June 2023 | No Comments
CMS has been very active in releasing significant guidance to support the Inflation Reduction Act (IRA) provisions for the Part Drug Inflation Rebate and the Drug Price Negotiation program.  Earlier…

2023 CMS Program Audit Trends and Key Details: What We Know So Far

| CDAG, CPE, FA, June 2023, ODAG, SNP-MOC | No Comments
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…

BluePeak provides fresh insight into the CMS Proposed Rule for 2024

| February 2023, Medicare, Part A, Part B, Part C, Part D | No Comments
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…

PACE Past Performance

| CMS, February 2023, PACE | No Comments
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…

Consultant Corner: Does Requiring Prior Authorization from Contracted Providers Benefit or Burden Medicare Advantage (MA) plans?

| Consultant Corner, February 2023, MA | No Comments
Lisa Barker is BluePeak Part C Lead Providers, Industry Groups and the Office of Inspector General (OIG) have been very vocal about concerns for prior authorization requirements creating barriers that…

Consultant Corner: Do Your ODAG Universes Have Integrity?

| Consultant Corner, November 2022, ODAG | No Comments
Jaymie Billbrough, RN, is a BluePeak senior health plan services consultant. Prior to 2022, The Centers for Medicare and Medicaid Services (CMS) provided Sponsoring Organizations (SO) with a 20% “margin…

Part D Operational Implications of the Inflation Reduction Act (IRA) of 2022

| IRA, November 2022 | No Comments
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…

Effective Strategies in Claims Quality Auditing

| MA, November 2022 | No Comments
In light of ever rising benefit costs, employers and Medicare Advantage (MA) plans should consider regular claims quality auditing as part of an overall benefits and cost-containment strategy. Claims audits…

Risks in Misclassifying First Tier, Downstream, and Related Entities (FDRs)

| MA, MCMG, Medicare, November 2022 | No Comments
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…

Minimizing Hospice Billing Concerns

| CMS, November 2022, Part D | No Comments
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…

CMS Continues to Scrutinize Part D Claims and Coverage Determinations Process through Program Audits and Notices of Non Compliance

| Fall 2022, Part D | No Comments
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…

CY 2022 Part C and Part D Reporting Technical Specifications – Do You Know What Has Changed?

| Fall 2022, Medicare | No Comments
In June, CMS issued updated technical specifications for CY 2022 Medicare Part C and Part D reporting. BluePeak has summarized the key changes in the technical specifications below. BluePeak compared…

CMS Announces Audits Targeting Fraud, Waste, and Abuse Beginning October 2022

| Audits, Fall 2022 | No Comments
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…

97% Isn’t Good Enough: Why Every Decision Matters

| Fall 2022, ODAG | No Comments
The Organization Determinations, Appeal and Grievances (ODAG) area of a Centers for Medicare & Medicaid Services (CMS) Program Audit focuses on high-risk areas with the greatest potential for enrollee harm. …

2023 CMS Program Audit Trends and Key Details: What We Know So Far

| CDAG, CPE, FA, June 2023, ODAG, SNP-MOC | No Comments
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…

Time to Dive into Self-Audit Season

| CMS, DME, ESRD, FDA, Part B, Part D | No Comments
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,…

ICYMI – BluePeak’s Articles posted recently on LinkedIn

| LinkedIn | No Comments
BPA Connection Matches Healthcare Job Seekers and Employers - https://www.linkedin.com/feed/update/urn:li:activity:6380517376378564608 BluePeak’s End-to-End Part C Claims Processing Audit Finds Deficiencies BEFORE CMS Does - https://www.linkedin.com/feed/update/urn:li:activity:6381527793406083073 BluePeak Shares “2019 Final Call Letter…

Effective Strategies in Claims Quality Auditing

| MA, November 2022 | No Comments
In light of ever rising benefit costs, employers and Medicare Advantage (MA) plans should consider regular claims quality auditing as part of an overall benefits and cost-containment strategy. Claims audits…

Highlights of the Final Rule

| CMS, Medicare, PACE | No Comments
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…

It is Always a Good Time to Think About Star Ratings

| HEDIS, MPF, Star Ratings | No Comments
As you checked your plan data that will be displayed on Medicare Plan Finder (MPF) for accuracy during the recent second plan preview, were you happy with your Star Ratings?…

PACE Past Performance

| CMS, February 2023, PACE | No Comments
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…

Initial Adoption of Indication-Based Formularies as a Formulary Management Tool

| CMS, Medicare, Part D | No Comments
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…

Ensuring a Pain-free Opioid Safety Strategy

| CARA, CMS, MME, OMS, Opioids, Part D | No Comments
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…

Perfect Storm

| CMS | No Comments
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…

ICYMI – BluePeak’s Articles Posted Recently On LinkedIn

| Ask the Expert, LinkedIn | No Comments
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…

Calling All SNP Plans

| News Alert | No Comments
Is your Special Needs Plan (SNP) due for a 2025 Model of Care (MOC) submission? With a due date of February 2024, we encourage you to not wait to review…

Senior Savings Model-Tips for a Successful Implementation

| Claims, CSR, Formulary, Part D | No Comments
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…

CMS announced they will be performing a 2021 transition of care audit using the Transition Requirements Analysis (TR)

| Uncategorized | No Comments
CMS announced they will be performing a 2021 transition of care audit using the Transition Requirements Analysis (TR) that was piloted back in 2019.  Although the 2019 TRA did not…

Medicare AEP is over and 2021 is right around the corner.

| AEP | No Comments
While compliance is a year-round expectation of the Centers for Medicare and Medicaid Services (CMS), plans are under even greater scrutiny by CMS and members alike at the beginning of…

ICYMI – BluePeak’s Articles Posted Recently On LinkedIn

| LinkedIn | No Comments
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…

OIG finds MAOs Inappropriately Denying Requests for PA and Payment, CMS agrees to Issue Stricter Guidance and update Audit Protocols and Auditor Training

| CMS | No Comments
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…
moving clock

Decreased HSD Tables Application Requirement Now Leads to CMS Network Adequacy Review Later

| CMS, HPMS, Medicare, Uncategorized | No Comments
Decreased HSD Tables Application Requirement Now Leads to CMS Network Adequacy Review Later Part C applications may have decreased requirements for the submission of a key management staff organizational chart…

The Centers for Medicare & Medicaid Services: 2024 Readiness Checklist for Medicare Advantage Organizations, Prescription Drug Plans

| CMS, December 2023 | No Comments
The Centers for Medicare & Medicaid Services (CMS) released the CY2024 Medicare Parts C and D Readiness Checklist on October 13, 2023. Although this is a busy time of year,…

BluePeak Services Spotlight: End-to-End Part C Claims Processing and Part D Claims Testing and Monitoring

| CMPs, CMS, Part C, Part D, Uncategorized | No Comments
In addition to the Centers for Medicare & Medicaid Services (CMS) program audits, a plan’s claims issues, such as not processing Low-Income Subsidies (LIS) correctly, can surface in one-third financial…

Will Your Grievance Resolution Letters Stand Up in an Audit?

| Audits, CMS, Medicare, Part D | No Comments
Across the Medicare Advantage and Part D industry, Plans are nervous about how their grievance resolution letters will present and stand the test in a CMS Program Audit. BluePeak Advisors…

Using Interim Staffing to bring Appeals and Grievances Timeliness into Compliance–A Case Study

| Compliance, IRE, MA, MA-PD, Part D, PBM | No Comments
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…

Top 4 Tips to Make 2022 Your Best Plan Year Yet

| Audits, CMS, Tips | No Comments
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…

Proposed American Jobs Plan Includes Provision for Medicaid

| Medicaid | No Comments
On March 31, 2021, President Biden, as part of the White House American Jobs Plan, proposed to increase federal support for home and community-based care by $400 billion over eight years…

Universe Monitoring Service Case Study and Service Spotlight

| CMS, IDS, Part C, Part D, UMS | No Comments
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…

Reconciling Skilled Nursing Facility Drugs Payment

| Audits, Part D, SNF | No Comments
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…

CMS to Provide Training on the New Medicare Communications and Marketing Guidelines at Upcoming Fall Conference

| ANOC/EOC, CMS, EOC, Marketing, MCMG, Medicare, Uncategorized | No Comments
As plans work through the biggest changes to the Medicare Marketing Guidelines since its inception – including changing the name of the guidance to the Medicare Communications and Marketing Guidelines…

A Message About COVID-19

| COVID19 | No Comments
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…

ICYMI – BluePeak’s Articles Posted Recently On LinkedIn

| LinkedIn | No Comments
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: CMS Announces Timeliness Monitoring…

Consultant Corner: Importance of Accurate Member Marketing Materials

| Consultant Corner, June 2023 | No Comments
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…
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