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…
BluePeak AdvisorsMay 29, 2020
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 AdvisorsApril 29, 2020
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…
BluePeak AdvisorsApril 18, 2020
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…
BluePeak AdvisorsMarch 24, 2020
Case Study During the course of a Medicare Program Audit the plan struggled with being able to generate accurate and compliant universes in a timely manner. The plan had experienced…
BluePeak AdvisorsMarch 22, 2020
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…
BluePeak AdvisorsMarch 18, 2020
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,…
BluePeak AdvisorsMarch 18, 2020
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…
BluePeak AdvisorsMarch 18, 2020
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…
BluePeak AdvisorsMarch 18, 2020
The Centers for Medicare & Medicaid Services (CMS) released an HPMS memo on August 20, 2019 providing an overview of the upcoming changes to program audits through 2021. These changes…
BluePeak AdvisorsMarch 18, 2020
On 2/28/2020, CMS released the Civil Money Penalty (CMP) Enforcement Actions for 2019 Program Audits. Contract year 2019 was the first year of this audit cycle and we have incorporated…
BluePeak AdvisorsMarch 18, 2020
On February 5, 2020, the Centers for Medicare & Medicaid Services (CMS) announced it will not be publishing a Call Letter for 2021. Rather, CMS is codifying guidance typically published…
BluePeak AdvisorsFebruary 25, 2020
In the 2021 and 2022 Policy and Technical Changes Proposed Rule, CMS is proposing routine measure updates and an increase in the weight of patient experience/complaints and access measures. It…
BluePeak AdvisorsFebruary 25, 2020
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…
BluePeak AdvisorsFebruary 25, 2020
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)…
BluePeak AdvisorsFebruary 5, 2020
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…
BluePeak AdvisorsDecember 17, 2019
In October, the National Health Care Anti-Fraud Association (NHCAA) held its annual training conference that spotlighted emerging fraud schemes. In addition to updates on the brace, genetic testing, and foot…
BluePeak AdvisorsDecember 17, 2019
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…
BluePeak AdvisorsDecember 17, 2019
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…
BluePeak AdvisorsDecember 17, 2019
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…
BluePeak AdvisorsDecember 17, 2019
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…
BluePeak AdvisorsSeptember 9, 2019
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?…
BluePeak AdvisorsSeptember 9, 2019
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 AdvisorsSeptember 9, 2019
The Centers for Medicare & Medicaid Services (CMS) released an HPMS memo on August 20, 2019 providing an overview of the upcoming changes to program audits through 2021. These changes…
BluePeak AdvisorsSeptember 9, 2019
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…
BluePeak AdvisorsAugust 2, 2019
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…
BluePeak AdvisorsJuly 10, 2019
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…
BluePeak AdvisorsJune 19, 2019
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…
BluePeak AdvisorsJune 12, 2019
On May 10, 2019, CMS published a final rule on Drug Pricing Transparency. The rule, effective July 9, 2019, requires direct-to-consumer television advertisements of prescription drugs and biological products payable…
BluePeak AdvisorsJune 11, 2019
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…
BluePeak AdvisorsJune 11, 2019
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