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- 9/8/2023 | CMS releases first part of the draft guidance for the Medicare Prescription Payment Plan (MPPP)
- 8/31/2023 | CMS Announces the First 10 Drugs Covered Under Medicare Part D Selected for Price Negotiation in Accordance with the IRA
- 5/24/2023 | CMS Program Audit Trends and Key Details: What We Know So Far
- 4/5/2023 | Announcement of Calendar Year (CY) 2024 Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies
- 3/24/2023 | Medicare Drug Price Negotiation Program for CY2026 Initial Guidance Released
In This Issue | September 2023
Discover Previous Issues
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…
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…
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…
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…
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…
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…
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…
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…
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…
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…
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…
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…
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…
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…
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…
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 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…
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…
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…
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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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…
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…
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…
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…
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…
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…
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…
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…
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…
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…
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…
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…
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…
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 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…
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…
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…
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…
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…
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'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…
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 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…
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…
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…
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…
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…
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…