A Centers for Medicare and Medicaid Services (CMS) One-Third Financial Audit (OFA) is when financial records of at least one-third (1/3) of Medicare Advantage (MA) and Prescription Drug Plans (PDPs)…
BluePeak AdvisorsMay 25, 2022
Industry News
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…
BluePeak AdvisorsMay 20, 2022
Risk adjustment is expected to receive additional focus and attention from federal regulators in the near term. Political and administrative changes frequently shift the focus and attention of oversight agencies,…
BluePeak AdvisorsMay 20, 2022
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…
BluePeak AdvisorsMay 9, 2022
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. …
BluePeak AdvisorsApril 14, 2022
Across the Medicare Advantage and Part D industry, Plans are nervous about how their grievance resolution letters will present and stand the test in a CMS Program Audit. BluePeak Advisors…
BluePeak AdvisorsFebruary 18, 2022
On February 9, 2022 CMS released the Medicare Advantage and Part D Communications & Marketing Guidelines (MCMG) reminding us all of what we already know- it’s time to begin planning…
BluePeak AdvisorsFebruary 12, 2022
The 2021 PDE submission deadline is June 29, 2022. Plans must attest to the accuracy of their submitted PDE records prior to CMS’ financial reconciliation. The challenge is that many…
BluePeak AdvisorsFebruary 12, 2022
Two rules have the potential to impact how Part D price concessions and pharmaceutical rebates are managed and how these changes, when implemented, will subsequently impact a Part D sponsor’s…
BluePeak AdvisorsFebruary 9, 2022
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…
BluePeak AdvisorsFebruary 9, 2022
The Centers for Medicare and Medicaid Services (CMS) requires, as part of the formulary submission process, each plan sponsor complete the Transition Policy Attestation through the formulary submission module in…
BluePeak AdvisorsFebruary 9, 2022
In view of ever rising benefit costs, employers and Medicare Advantage plans should consider a medical claims audit as part of an overall benefits and cost-containment strategy. Medical claims audits…
BluePeak AdvisorsFebruary 9, 2022
Transition is highly scrutinized and frequently audited within the Medicare Part D program. For 2021, the Centers for Medicare & Medicaid Services (CMS) performed the Transition Requirements Analysis (TRA) to…
BluePeak AdvisorsDecember 17, 2021
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…
BluePeak AdvisorsOctober 26, 2021
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…
BluePeak AdvisorsOctober 26, 2021
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…
BluePeak AdvisorsOctober 26, 2021
The following are summaries of Rules that contain big changes for group health plans and individual health plans. SummaryInterim Final Rule with Comment Period Requirements Related to Surprise Billing; Part…
BluePeak AdvisorsJuly 29, 2021
The Centers for Medicare & Medicaid Services (CMS) recently released a proposed rule titled “Patient Protection and Affordable Care Act; Updating Payment Parameters, Section 1332 Waiver Implementing Regulations, and Improving…
BluePeak AdvisorsJuly 12, 2021
Now that bids have been submitted, it is time to start thinking about 2022 compliance and operations. One of the best ways to prepare for audit success and happy members…
BluePeak AdvisorsJune 11, 2021
With the 2021 Program Audit in full swing, CMS released the Program Audit Protocols for 2022 on May 26, 2021. The 2022 protocols are very similar to what was previously…
BluePeak AdvisorsJune 11, 2021
In addition to CMS performing numerous program audits thus far in 2021, recent memos have denoted that CMS is moving forward with several self-audits for plans to consider. In April,…
BluePeak AdvisorsJune 11, 2021
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…
BluePeak AdvisorsJune 11, 2021
On May 25, 2021, the Department of Health and Human Services (HHS) announced that it would again interpret and enforce the Section 1557 of the Affordable Care Act (Section 1557)…
BluePeak AdvisorsMay 26, 2021
On Friday May 28th, at 5pm ET, CMS will provide Plan Sponsors access to the new HPMS marketing module. The new marketing material module has enhanced functionality and will provide…
BluePeak AdvisorsMay 26, 2021
On March 31, 2021, President Biden, as part of the White House American Jobs Plan, proposed to increase federal support for home and community-based care by $400 billion over eight years…
BluePeak AdvisorsMay 12, 2021
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…
BluePeak AdvisorsMarch 12, 2021
New COVID-19 Related Audit Considerations In addition to all of the other usual audit concerns, Plan Sponsors should also be prepared for CMS to scrutinize all things COVID-19 related. As…
BluePeak AdvisorsMarch 12, 2021
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…
BluePeak AdvisorsMarch 12, 2021
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…
BluePeak AdvisorsMarch 7, 2021
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…
BluePeak AdvisorsMarch 5, 2021
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