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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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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. …

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…

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…

More Rigorous CMS Oversight and Audit Activity Ahead

| Audits, CMS | No Comments
More Rigorous CMS Oversight and Audit Activity Ahead Audit notices are already hitting inboxes as CMS is kicking off a longer than usual Program Audit season this year (March through…

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…

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…

CMS Releases Final Rule on Interoperability and Patient Access

| CMS, MA, Uncategorized | No Comments
On March 9, 2020, the Centers for Medicare & Medicaid Services (CMS) released the final rule (CMS-9115-F) regarding Interoperability and Patient Access. While CMS issued a fact sheet regarding this rule, this rule…

Consultant Corner: Inflation Reduction Act Implementation Best Practices and Planning for the Future

| Consultant Corner, IRA | No Comments
Jeff Baker, is a BluePeak Senior Health Plan Services Consultant. On August 16th, the Inflation Reduction Act of 2022 (IRA) was signed into law.  The text of the bill is…

Interoperability– Everything You Wanted to Know

| Interoperability | No Comments
As the date for compliance with the Interoperability Rule draws closer, BluePeak answers all of your questions, to help you stay in the know. 1 Question: I read the required…

Potential Changes on the Horizon for 2020 and Beyond

| CMS, FDRs, HPMS, Medicaid, Medicare, Star Ratings, TPMA | No Comments
After getting ready for all the changes a new contract year brings, Medicare Advantage (MA) Plans and Part D sponsors await the issuance of the Draft Call Letter for early…

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…

In the News…

| FDA | No Comments
Unapproved Drugs Initiative Terminated On November 20, 2020 The Department of Health and Human Services terminated the Unapproved Drugs Initiative. The 2006 Unapproved Drug Initiative requires manufacturers to submit drugs…

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. …

New Audit Protocols are Coming in 2021

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

Encounter Data – It’s Not Just Claims Data Anymore.

| CMS, Compliance, MA, Part C, Part D | No Comments
Background On September 14, 2020 CMS released The Advance Notice of Methodological Changes for Calendar Year (CY) 2022 for Medicare Advantage (MA) Capitation Rates and Part C and Part D…

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 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…

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…

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…

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…

5 Universal Strategies to Move the Needle on Star Rating Improvements: A Medication Adherence Case Study

| Medicare, Part C, Part D | No Comments
One of the surprises in the release of plans’ Star Ratings results for the 2019 open enrollment season was that Star Ratings around Part D adherence scores, on average, slipped.…

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…

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 Podcast: Initial Thoughts on CMS 2018 Spring Conference

| Podcast | No Comments
Tune into BluePeak’s newest podcast, to hear Principal Babette Edgar and Senior Consultant Susan Herman discuss their initial thoughts on last week’s CMS 2018 Medicare Advantage & Prescription Drug Plan Spring…

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?…

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…

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…

BluePeak Podcast: Cost of Non-Compliance

| CMPs, CMS, Podcast | No Comments
The Facts are Sobering: CMPs may be the least expensive part of being non-compliant. CMS audits are on the rise, as are CMPs and sanctions. The average CMP is around…

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…

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…

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…
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