BluePeak Advisors Case Study

BluePeak’s strategic compliance support helped deliver a perfect 0.00 CMS Program Audit result.

Executive Summary

One of BluePeak Advisor’s (BluePeak) premier clients has partnered with us for more than a decade to strengthen its Medicare operational and compliance framework. Following their CMS Program Audit over 10 years ago, the client engaged BluePeak to support the organization through significant CMS sanctions and remediation efforts. The organization continued to rely on BluePeak for ongoing strategic, operational, and compliance support during periods of internal growth and transition to present day.

In late 2024, this client prepared for the 2025 Plan Year, as well as significant changes in compliance leadership, BluePeak was again re-engaged to provide comprehensive advisory compliance services, including, but not limited to CMS Program Audit readiness activities. When the client received notice of its 2025 full CMS Program Audit the Spring of 2025, the organization sought BluePeak’s expertise to ensure a successful audit from start to finish.

Leveraging years of historical knowledge and partnership and prior remediation groundwork, BluePeak supported all major program areas including Formulary Administration (FA), Coverage Determinations, Appeals and Grievances (CDAG), Organization Determinations, Appeals and Grievances (ODAG), and Compliance Program Effectiveness (CPE).

CMS Program Audit Support included subject matter expertise, universe and case review, strategic analysis, and guidance for both our client and its First Tier, Downstream, and Related Entities (FDRs). This longstanding and valued partnership positioned BluePeak’s client to approach the 2025 CMS Program Audit with strengthened processes, enhanced oversight, and confidence in its compliance program execution.

The Challenge

Challenge 01

Comprehensive Audit Preparation

Ensuring readiness for a full CMS Program Audit across multiple areas, including documentation, universe validation, and compliance alignment.

Challenge 02

Adapting to Internal Growth

Aligning compliance processes with organizational changes and operational growth to maintain audit readiness.

Challenge 03

Real-Time Audit Management

Responding to CMS inquiries and managing logistical challenges during the audit with accuracy and confidence.

Objective

The goal was clear: Exit the CMS Program Audit
with little to no findings – a tall order!

Methodology

BluePeak worked with this client to establish a tailored audit‑support framework focused on preparing for the logistical and operational demands of the CMS Program Audit. Key priorities included implementing best‑practice approaches to audit management, improving case review processes, and strengthening internal education for future audits.

BluePeak assigned dedicated subject matter experts to each program area to collaborate closely with Compliance leadership and operational teams. In addition, a BluePeak Project Manager oversaw deliverables, CMS inquiries, and timelines, while a BluePeak executive provided senior‑level oversight and escalation support throughout the audit process.

Solutions Implemented

1

Audit Readiness Prep

  • Reviewed all audit-requested documents for completeness and strategy.
  • Discussed how to convey the best offering to the CMS program auditors.
2

Review of Universes

  • Provided validation of universes.
  • Identified potential areas of weakness.
  • Helped prepare for potential inquiries.
3

Audit Sessions

  • Attended the client’s audit sessions with CMS when warranted and approved.
  • Provided real-time guidance on how to respond to questions and inquiries.
4

Post – Audit Support

  • Reviewed inquiries from the client’s team and CMS auditors.
  • Strategized and provided guidance on how best to respond to questions.
  • Reviewed draft report and answered questions posted.
  • Made recommendations on best practices.

Results

Audit Outcome

0.00
Final Overall Audit Report Score
0
CAR Findings
0
ICAR Findings
No corrective actions required across FA, CDAG, ODAG, and CPE.

As a result of collective efforts and commitment by our client with the assistance of
BluePeak, our client did not have any issues of non-compliance noted as Corrective
Action Required (CAR), or Immediate Corrective Action Required (ICAR) across any of the program areas: FA, CDAG, ODAG, and CPE. Ultimately achieving a final overall audit report score of 0.00.

Conclusion

BluePeak offers a practical, tactical approach to CMS Program Audit preparation—helping plan sponsors anticipate requirements, respond effectively, remediate issues, and build sustainable best practices. With deep experience and insight into evolving CMS audit priorities and methodologies, BluePeak is a strong partner for organizations, especially new or small to mid‑size Medicare Advantage plans navigating a complex and rapidly changing regulatory environment.