PBM – Compliance Details

  • CMS Mock Audits: One of the most important activities that you can perform to get ready for CMS audits is practice universe pulls and mock CMS audits. BluePeak can assist you with preparation and quality checks of universes, training of staff to present during the CMS audits and provide subject matter expertise in each of the CMS audit program areas.  We employ former CMS auditors so that we can execute a mock audit just as CMS will perform the audit.  The mock audit final report will contain information that will allow you to understand exactly where the issues lie and will give you actionable tasks that will allow you to remediate BEFORE CMS identifies the issues.
  • CMS Audit Support: During an actual CMS audit, BluePeak can assist with universe review and preparation, document and impact report preparations, coaching of staff and questions to ask or not ask CMS.  We can be available onsite to support your teams.  After the audit, BluePeak can assist with strategies for corrective actions, Corrective Action Plan (CAP) writing and review, and perform actual remediation work if needed.  We can work with the business leads to design project plans, allocate resources and implement corrective actions.  We can then perform a mock validation audit before CMS remediation dates to assure you that you have remediated all items to CMS’ satisfaction.
  • Universe Monitoring System (UMS): BluePeak understands the impact Invalid Data Submissions can have on a plan’s CMS Program Audit score, subsequent validation audit and past performance. Our Universe Monitoring Service (UMS) is an audit-readiness resource for plans. Our service reviews your universe data for technical issues and to identify potential operational issues. We use a proprietary analytics system, unique to the universes for each program audit area, to identify potential underlying issues.
  • Prescription Drug Event (PDE3™): BluePeak’s PDE3 service allows plan’s to “Monitor, Manage & Maximize” their current PDE process and records, validate quarterly Coverage Gap Discount payments and mitigate future PDE rejections. Our PDE experts will work with your team to validate the accuracy of your PDE records and reconcile CMS financial reports, including annual PDE reconciliation.
  • Plan Benefit Testing: BluePeak understands how administering incorrect benefits can negatively impact the beneficiary causing a potential increase in calls and grievances.  BluePeak can assist with validating benefits are setup and are being administered consistently with the CMS approved formularies and bid documents.  We will collaborate with your team to determine the best solution to ensure cost-sharing is accurate thorough all benefit phases and claim processing is consistent with CMS rules and regulations.
  • Fraud, Waste and Abuse (FWA) Analysis: The BluePeak FWA Program includes a comprehensive approach that helps detect and resolve issues of FWA at the member, provider and pharmacy levels. BluePeak works with our clients to address and report these issues. The program is comprised of a holistic commitment to detect, prevent and control FWA. The basic components of the program include: Training and Education, Monitoring and Detection, and Investigating and Action Plans.
  • Policy and Procedure Review and Writing: We can assist PBMs in drafting and reviewing policies and procedures, not only from the pure writing standpoint, but assuring that the operations of your organization are compliant and efficient leading to the saving of time and money.
  • Staff Training: Many of CMS’ findings are a result of inadequate training of staff in the various business areas. BluePeak can develop customized training programs to meet your needs and ‘train the trainers’ or deliver that training to your staff.  Developing training programs can be time and resource consuming, and BluePeak can take the burden off of your hands.
  • Healthcare Policy Analysis and Application: BluePeak understands the burden that daily HPMS memos can place on PBMs, especially small to midsize PBMs, who may not have the resources to monitor and interpret daily..  BluePeak monitors, analyzes, and summarizes key Medicare legislation, state/federal regulations, and other CMS issued guidance.  We can provide training on policy related issues for executives, directors, and staff and assess how policy developments impact specific business and operational areas of your business.  We can then develop and implement practical and actionable steps so PBM clients can proactively address policy driven operational challenges and business opportunities head on.
  • Interim Staffing: BluePeak can provide PBM experienced compliance and operational professionals to assist your staff or when you may need some temporary extra support, or when you have had unexpected resignations. Our team will also assist you with hiring the right people, with the right skill sets for your specific organization.
  • Oversight and Monitoring Programs: One of the major reasons PBMs get into trouble is that they do not have an effective, robust, compliant internal and/or downstream vendor monitoring program.  BluePeak can develop or assist you in developing a customized program that is CMS compliant, while able to be operationalized with limited time and human resources from a plan perspective.

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