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.
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BluePeak News Alerts
- April 5th 2024 | Final Rule Suggests Continued Focus on Termination of Skilled Nursing Facility Services, Home Health and Outpatient Rehab
- March 7th 2024 | BluePeak publishes summary of M3P Final Part One Guidance Summary including next steps for Plan Sponsors to consider
- February 15th 2024 | CMS published memorandum Medicare Prescription Payment Plan: Draft Part Guidance
- February 13th 2024 | CMS published a Final Rule on Medicare and Medicaid Programs; Patient Protection and Affordable Care Act and so much more
- December 19th 2023 | Breaking News: Medicare Advantage Utilization Management (UM) under scrutiny
In This Issue | Spring 2024
Discover Previous Issues
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,…
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…
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…
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)…
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…
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…
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…
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…
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…
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…
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…
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…
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 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…
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…
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…
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…
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…
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 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…
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…
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 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. …
Explore more articles
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…
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…
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…
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…
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…
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…
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…
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 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…
BluePeak is pleased to announce our most significant move yet to enhance the services we bring to our valued clients. Effective today, BluePeak Advisors has merged with Gallagher. With operations in more than 35 countries and client-service capabilities in more than 150 countries, Gallagher is a Fortune…
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…
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…
2019 is already off to a blazing start with the implementation of Medicare Part D plans’ new opioid edits as well as 2020 formulary development. While plans are already preparing…
The Centers for Medicare and Medicaid Services (CMS) proposes changes to Star Ratings, validation audits, annual Compliance Program Effectiveness (CPE) audits, Part D opioid overutilization policy, and more in the…
On February 9, 2022 CMS released the Medicare Advantage and Part D Communications & Marketing Guidelines (MCMG) reminding us all of what we already know- it’s time to begin planning…
On December 6, 2019 CMS issued the HPMS Memo titled “Proposed Collection for New Medicare Part C and Part D Program Audit and Industry-Wide Part C Timeliness Monitoring Project (TMP)…
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…
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…
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,…
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)…
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…
Over the course past year, CMS issued several different proposed and final rules that address making certain data available in a real-time or near real-time manner. The table below summarizes…
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…
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…
President Biden hit the ground running, signing a batch of Executive Orders just hours after he was sworn in as the 46th President of the United States. A couple of…
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…
On April 30, 2019, Health and Human Services (HHS) published a final rule in which they are exercising their discretion in how they apply regulations concerning the assessment of Civil…
CMS Account Managers May Contact Plans to Assess New Medicare Card Project Readiness PDE Self-Audits Cost At Least One Plan Over $1 Million in Claims Reversals CMS to Conduct Provider…
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…