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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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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. …

Program Audit Consistency Teams (PACTs)

| Audits, CMS, Medicaid, Medicare | No Comments
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…

CMS Fraud Conference–Working Together to Combat Fraud

| CMS, FWA, Medicare, Part B, Part C, Part D | No Comments
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…

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…

Question & Answer

| Legal, PBM | No Comments
Q: Is it permissible for the Compliance Officer to report to General Counsel or the Legal Department?  A: While some Plans and PBMs do this, it is not ideal or…

Is Your Opioid Program Compliant?

| CARA, CDAG, FA, 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…

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…

Is Your Organization Doing All You Can to Detect, Prevent and Correct HIPAA Violations?

| Audits, CMPs, HIPAA, OCR | No Comments
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…

Got Data?

| CMS, Data Reporting, IRE, Part C, Part D | No Comments
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…

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?…
Tips

BluePeak Offers Tips for Developing 2018 Risk Assessments and Monitoring and Auditing Work Plans

| Audits, CMS, CPE, FDRs | No Comments
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 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…

Proposed Rule Aimed at Drug Price Transparency Could Lead to Inadvertent Member Confusion

| CMS, Medicare, Part C, Part D, PBM | No Comments
On October 18, 2018, the Centers for Medicare & Medicaid Services (“CMS”) published a proposed rule which, if finalized, will amend the Medicaid and Medicare Parts A, B, C, and…

What are you doing to improve your Star Ratings?

| EHR, EMR, MPF, Part C, Part D, 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?…
Hand holding a sparkler

New Year’s Day is Ultimate Test of New Part D Plan Year Readiness

| Audits, CDAG, CTM, FAA, PBM, TPMA | No Comments
While most people are singing Auld Lang Sine at midnight on January 1, those of us in the Medicare world are anxiously awaiting the first claims of the plan year…

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…

CMS Expands Penalties in 2017: One-Third Financial Audit Findings Will Cost You More This Year

| CMPs, CMS, Medicare, News, Uncategorized | No Comments
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…

The 2019 CMS Program Audit Season is Upon Us!

| Audits, CDAG, CMS, CPE, FA, ODAG, SARAG, SNP-MOC | No Comments
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…

CMS Placing More Scrutiny on MTM

| CMS, MTM | No Comments
Hot Topic MTM has become a popular topic with CMS not only at their Spring conference but also as a new pilot for their Program Audits.   CMS is placing more…

CMS Discusses Draft 2019 Audit Protocols and More at Conferences

| Audits, CMS, Uncategorized | No Comments
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…

Want to know what you missed if you didn’t receive an audit notice in 2022?

| Consultant Corner | No Comments
Carmen Winters, a BluePeak senior consultant, provided 2022 CMS program audit support to many clients. Read about her observation regarding CMS auditor focus on Quality of Care during the 2022…

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…

BluePeak Service Spotlight: Universe Monitoring Service

| Audits, CMS | No Comments
On February 8, 2019, CMS released “CMS Program Audits Frequently Asked Questions (FAQs).  One of the questions addressed  was: “Will sponsoring organizations always have the opportunity to submit universes up…

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…

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…

CMS Increases Part D Self Audits Targeting Payment and Benefit Inaccuracies from PDE Data

| Audits, Claims, CMS, COVID19, ESRD, MME, Part A, Part B, Part D | No Comments
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…

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…

2019 Program Audits Reflect Continued Improvement

| Audits | No Comments
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…

Service Spotlight: Member Material Review

| Service Spotlight | No Comments
Are you drowning in developing and reviewing member material? Accuracy and timeliness are critical in all member communications.  BluePeak’s consultants have experience reviewing member materials from their work at Plans…

Ensuring Record Retention Requirements with First-tier, Downstream and Related Entities (FDR’s).

| FDRs, Medicare, Part D, Uncategorized | No Comments
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…
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…
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