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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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Part D Audit Insights for CY2024: Key Takeaways

| Fall 2024, Part D | No Comments
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…

Should Off-cycle MOC Submission Be a Priority, RIGHT NOW?

| Fall 2024, MOC, NCQA | No Comments
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…

2024 Audit Trends: Special Needs Plans

| Audits, Fall 2024 | No Comments
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:…

2025 Plan Readiness: Are You Prepared?

| CMS, Fall 2024, IVR, M3P, Member Materials, Part C, Part D, SSBCI | No Comments
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…

Upcoming IRA Changes for 2025: Key Considerations for Year End Testing

| Audits, CMS, Summer 2024 | No Comments
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…

Understanding Dual-Eligible Special Needs Plans (D-SNPs): Your essential guide to types of D-SNPs and the impact of MMPs Sunsetting

| CMS, D-SNP, MMP, Summer 2024 | No Comments
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…

Consultant Corner: Updates to the Plan Communication User Guide That Require Attention

| Audits, Consultant Corner, Summer 2024 | No Comments
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…

2024 Utilization Management (UM)- Focused Audits: Lessons Learned

| Summer 2024, Utilization Management | No Comments
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…

What Risk Does the new TERM Table Really Pose?

| Audits, Medicare, Part D, Spring 2024, Utilization Management | No Comments
Have you heard about the new table initially required in the CMS Utilization Management (UM)-Focused audits? Also, known as “Table 7”, Plans need to ensure an ability to report accurate…

What we know so far about 2024 Utilization Management Focused Audits

| Audits, CMS, Spring 2024 | No Comments
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…

The Part D Tongue Twister and Brain Teaser also known as the Medicare Prescription Payment Plan

| IRA, Part D, Spring 2024 | No Comments
The Inflation Reduction Act (IRA) was signed into law in August 2022 with the goal of expanding Part D benefits, lowering drug costs, and improving the sustainability of the Medicare…

The Importance of Medicare Marketing Material Development and Review, New changes coming and 2024 finding examples

| CMPs, CMS, IRA, Medicare, NABA, NONC, Part D, Spring 2024 | No Comments
Member materials are an important part of the Medicare member experience with a plan. Each year as Plan Sponsors finalize their product bid filing, CMS releases the upcoming plan year…

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…

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…

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…

Avoiding a Perfect Storm-Proactive Testing and Claims Oversight is Key

| Compliance | No Comments
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…

Common Findings by Program Area

| Audits, Claims | No Comments
Common Findings by Program Area In addition to ensuring compliance with COVID-19-driven changes, it is equally important to keep in mind lessons learned from prior audits when preparing for the…

BluePeak’s Summary of the September 2018 Medicare Communications and Marketing Guidelines (MCMG)

| CMS, Marketing, MCMG | No Comments
On July 20, 2018, the Centers for Medicare & Medicaid Services (“CMS”) released the Medicare Communications and Marketing Guidelines (“MCMG”), replacing the Medicare Marketing Guidelines and all associated guidance in…
laptop and stethoscope

You’re Going to Want BluePeak’s Online Provider Directory Review Service

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

Is Your Plan Ready for the New Year?

| CMS, MBI, Medicare, Open Enrollment, Part D | No Comments
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…

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)…

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…

Part B Drug Timeliness Monitoring and Management

| CMS, ODAG, Part B, Uncategorized | No Comments
On May 23, 2019, the Centers for Medicare & Medicaid Services (CMS) published a final rule (CMS-4180-F) which adopted new processing timeframe requirements for preservice organization determinations and plan reconsiderations…

Civil Money Penalty Rates Increasing

| CMPs | No Comments
On April 8, 2022, CMS released the updates to the standard Civil Money Penalty (CMP) amounts that will be used for the next three years beginning with plan year 2022. …

ICYMI – BluePeak’s Articles posted recently on LinkedIn

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

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…

Arthur J. Gallagher & Co. Acquires BluePeak Advisors, LLC

| Press Releases | No Comments
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…

Early Release of Medicare Advantage and Part D Advance Notice:  Part C & D Star Rating Changes

| MA, Part C, Part D, Star Ratings | No Comments
CMS published Part I of the Advance Notice of Methodological Changes for Calendar Year (CY) 2022 for Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies…

Medicare Advantage and Prescription Drug Plan Appeals Guidance– Are You Ready?

| HPMS, Medicare, PDBM | No Comments
Chapter 13 of the Medicare Managed Care Manual (MMCM) and Chapter 18 of the Prescription Drug Benefit Manual (PDBM) have been consolidated into one chapter. CMS announced the release of…

Best Practices in Plan and Prescriber Interactions-Improving the Organizational Determination and Coverage Determination Process

| Audits, CD, CMS, OD | No Comments
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…

2021 and 2022 Policy and Technical Changes Proposed Rule Could Impact Drug Management Programs

| DMP | No Comments
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…

Helpful Hints to Prepare for a Remote Audit

| Audits, Tips | No Comments
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…

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

| MAO, OIG | 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…

Risk-Adjustment Data Validation Readiness: Key Strategies for Compliance

| CMS, HCC, OIG, Winter 2024 | No Comments
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…

Step-by-step Guide to Developing an Effective Auditing and Monitoring Plan

| Audits, Compliance | No Comments
The Fourth Quarter is when most Plans work to finalize their risk assessment and their auditing and monitoring plan for the coming year. This is a good time to think…

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…

Changes Ahead for Plan Finder

| CMS, HPMS, MA | No Comments
During the CMS Spring Conference on May 1, 2019, CMS reviewed some of the revisions that are being made to Plan Finder. The redesigned Plan Finder will be used this…

Consultant Corner: Updates to the Plan Communication User Guide That Require Attention

| Audits, Consultant Corner, Summer 2024 | No Comments
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…

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…

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…

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…

CMS Updates Definition of Marketing, Reduces Required Hard Copy Member Materials

| CMS, Marketing, MCMG, Medicare | No Comments
The Centers for Medicare and Medicaid Services (CMS) typically issues a draft version of the Medicare Marketing Guidelines (MMG) early in the year for comment before releasing the final version…
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