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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.

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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. …

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…

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…

BluePeak’s Definitive Guide to Preparing for 2020

| CMS, Marketing, MCMG, PDE, Training | No Comments
Bids were turned in the first Monday in June and now it is time to implement those benefits, plan designs and formularies that your organization has been hard at work…

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…

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…

Reconciling Skilled Nursing Facility Drugs Payment

| Audits, Part D, SNF | No Comments
Recent 1/3 Financial Audits have focused on the accuracy of billing of medications while a member is in a skilled nursing facility (SNF).   Most drugs administered during an acute stay in…

Another Symptom of COVID-19-Fraud

| COVID19 | No Comments
CMS issued a Fraud Alert on COVID-19 schemes on March 23 and additional guidance was released via HPMS on April 1st.  On April 16th, the National Health Care Fraud Anti-Fraud…

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 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…

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…

ICYMI – BluePeak’s Articles Posted Recently On LinkedIn

| LinkedIn | 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: CMS Announces Timeliness Monitoring…

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…

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…

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…

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…

Financial Audits: Lessons Learned

| CMS, PDE | No Comments
Financial audits are just one of the many types of Medicare Part D audits.  Financial audit frequency and awareness continues to increase, and plans are realizing that they must integrate…

Highlights of CMS-Proposed Changes in Draft 2019 Call Letter

| CMS, CPE, Part C, Part D | No Comments
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…

Top 10 Audit Tips

| Audits, CMS, Tips | No Comments
Here are some tips to help ensure your Plan is adequately prepared as audit season gets underway for 2021. Ensure your plan and all of its delegates can produce accurate…

Prepared to Implement the CMS Preclusion List Requirement?

| CMS, Part D | No Comments
Along with the new year also comes a new CMS requirement known as the Preclusion List. This requirement was adopted in the April 2018 final rule as an alternative to…

Audit Experiences Underscore the Importance of the Additional Beneficiary Information Initiatives (ABBI) Database

| Audits, CMS, MA-PD, PDE | No Comments
Prior to 2019, plan sponsors were required to make an effort determine whether an immunosuppressant should be paid under Part D or Part B based upon information they had 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…

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…
prescription drugs

PDE SELF AUDITS in 2018

| CMS, Part C, Part D, PDE | No Comments
Throughout 2017, CMS continued its vigilance over drug claim payments by conducting Prescription Drug Event (PDE) Self-Audits. The drugs under audit in 2018 may change, but CMS has not yet…

‘Tis ALWAYS the season….for rejected claims analysis.

| CMS, PBM | No Comments
As year-end approaches, most plans are conducting claims testing to ensure that formularies and benefits are administered correctly on January 1 and beyond.  Plans and PBMs alike that have experienced…

New OD/CD Withdrawal Guidance Released

| CMS, Medicaid, Medicare, Part C, Part D | No Comments
NEW! Beginning January 1, 2022, plans must send a written notice of dismissal for Part C OD and reconsideration requests as well as for Part D CD and redetermination requests…

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…

2018 is Around the Corner – Are You Ready?

| ANOC/EOC, CMS, Compliance, CPE, CTM, HPMS, PBM, Uncategorized | No Comments
Bid approved – check. Member materials sent to printer – check. What other items should be on your radar over the next few months? The Centers for Medicare and Medicaid…

Highlights of the Final Rule

| CMS, Medicare, PACE | No Comments
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…

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. …

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…
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