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…
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…
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…
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 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…
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…
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…
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…
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)…
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…
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…
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. …
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…
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…
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…
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…
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…
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…
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…
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…
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…
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…
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…
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…
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…
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…
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…
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…
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…
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…