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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. 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. Read through our past articles and let us be your trusted source in the ever-changing world of healthcare.

Discover Previous Issues

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…

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

| CMS, 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…

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…

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…

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. …

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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…

ICYMI – BluePeak’s Articles Posted Recently On LinkedIn

| LinkedIn, Uncategorized | 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: Audit Tip #3-- It’s…

CMS Increases Percentage of Encounter Data on Which MA Plans’ Payments are Based

| CMS, FWA, Part D, PDE, RAPS | No Comments
According to the Final Call Letter, the Centers for Medicare and Medicaid Services (CMS) will increase the percentage of encounter data, on which part of Medicare Advantage plans’ pay is…

HHS Comes Full Circle: Section 1557 Regulations Again Interpreted to Prohibit Discrimination Based on Sexual Orientation and Gender Identity

| HHS | No Comments
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)…

Provider Directory Accuracy Monitoring and Use of the National Plan & Provider Enumeration System (NPPES)

| CMS, Part C, Part D | No Comments
On March 11, 2020 the CMS Part C and D User Call focused on Provider Directory accuracy and how the NPPES may support such accuracy.  In case you missed it,…

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…

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…

Big Changes Ahead for Group Health Plans and Individual Health Plans

| Legal, Summaries | No Comments
The following are summaries of Rules that contain big changes for group health plans and individual health plans. SummaryInterim Final Rule with Comment Period Requirements Related to Surprise Billing; Part…
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…

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…

Appeals and IRE Data Issues Can Impact Audit Scores, Star Ratings and CMPs  

| CDAG, CMPs, ICARs, IRE, ODAG | No Comments
Whether deficiencies are discovered as part of a CMS program audit or a Timeliness Monitoring Project (TMP) review, issues with appeals and Independent Review (IRE) data can impact a plan’s Star Ratings…

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?…

CMS Continues to Deploy Revised Strategies to Assist with Identifying and Deterring Opioid Abuse

| CMS, MAT, Medicare, MME, Opioids, Part D, PBM | No Comments
To assist Medicare Part D sponsors with monitoring efforts and potentially avoid overutilization of opioids in the elderly Medicare population, CMS has deployed numerous strategies over the past several years…

Formulary Strategy Planning for 2020-Indication Based Formulary Design Considerations

| CMS, EOC, FDA, Part D | No Comments
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…

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…

Annual Transition Policy and Attestation Submission to CMS

| CMS, HPMS, Part D | No Comments
The Centers for Medicare and Medicaid Services (CMS) requires, as part of the formulary submission process, each plan sponsor  complete the Transition Policy Attestation through the formulary submission module in…

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…

CMS Annual Report Shows Audit Scores and CMPs Decreased, Common Conditions Repeated in 2017

| Audits, CMPs, CMS, CPE | No Comments
From 2016-2017, audit scores were lower in all areas, except Compliance Program Effectiveness (CPE); Civil Money Penalties (CMPs) were significantly reduced; and most Common Conditions were repeated, according to the…

Top 5 Tips to Prevent a Part D Transition Finding

| Tips | No Comments
Transition is highly scrutinized and frequently audited within the Medicare Part D program. For 2021, the Centers for Medicare & Medicaid Services (CMS) performed the Transition Requirements Analysis (TRA) to…

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. …

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…

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…

BluePeak Service Spotlight: Mock Audits with UMS and Call Log Reviews

| Call Log Review, CMS, UMS | No Comments
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 Shifts Sales and Marketing Monitoring and Oversight to Plans

| CMS, CPE, CTM, Part D | No Comments
Executive Summary Since 2013, the Centers for Medicare & Medicaid Services (CMS) has steadily shifted direct monitoring and oversight of sales and marketing from the agency to plans. The removal…

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…

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…

Medicare Communications Marketing Guidelines: A Primary Topic at the CMS Fall Conference

| CMS, EOC, HPMS, Marketing, MCMG, Medicare | No Comments
BluePeak Highlights the Changes to MCMG Requirements The Centers for Medicare & Medicaid Services (CMS) 2018 Medicare & Prescription Drug Plan Fall Conference and Webcast kicked off on Thursday, September…

BluePeak Service Spotlight: Member Material Review

| CMS, EOBs | No Comments
BluePeak’s consultants have experience reviewing member materials from their work at Plans and for the Centers for Medicare and Medicaid Services (CMS). We can help you populate and/or review the…

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…