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BluePeak is a leading national healthcare consultancy that focuses on government programs.

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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 of universes, training of staff to present during the CMS audits and provide subject matter expertise in each of the CMS audit areas. We employ former CMS auditors so that we can execute a mock audit just as CMS will perform the audit. The 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.

  • Operations Mock Audit: Formulary Administration (FA); Part D Coverage Determinations, Appeals and Grievances (CDAG); Part C Organization Determinations, Appeals and Grievances (ODAG); and Special Needs Plan-Model of Care (SNP-MOC)
  • Mock Compliance Program Effectiveness Audit (CPE)
  • Mock Audit: Medicare-Medicaid Plan (MMP): Medicare-Medicaid Plan Care Coordination & Quality Improvement Program Effectiveness (MMP-CCIPE) and Medicare-Medicaid Plan Service Authorization Requests, Appeals and Grievances (MMP-SARAG)
  • Enrollment
  • Call Center
  • 1/3 Financial Audits

Universal Monitoring System (UMS)

Every plan should be monitoring their universe data on a regular basis, but the reality is that universe monitoring competes with the organization’s other priorities and resources and gets pushed to the back burner. BluePeak developed UMS, an audit-readiness resource for plans that:

  • Reviews Universes for technical issues
  • Analyzes and Identifies risk and outliers
  • Coaches your team and FDRs on presenting the data.

Year-End Benefits Testing

BluePeak can perform Year-end Benefit Testing for your Part C and Part D plans to ensure compliance. The member experience is the most critical reason for ensuring the benefits are set up accurately. However, claims adjudication errors can result in audit findings and issues of non-compliance. CMS continues to focus on claims accuracy for both Part C and Part D through Program Audits and Financial Audits. In addition, on the Part D side other audits such as Timeliness Monitoring and PDE Self Audits also focus on claims accuracy.

Audit Preparation and Onsite CMS and State 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 validation audit prior to the clean period to ensure the issues have been remediated.

Independent Validation Audits (IVA)

BluePeak can assist plans with the CMS IA validation process. Our team will work with your team to develop a CMS-approved validation work plan, conduct the validation audit and provide the validation report to be shared with CMS.

Operational Gap Analysis

Assessments are an effective way to evaluate the effectiveness of your operational processes. BluePeak will provide an analysis of plan operations to identify gaps where the Medicare Advantage Plans, Part D Sponsors or PBMs are not meeting CMS regulations and guidelines. We can do this across the plan or in specific areas where you think there may be issues. We will then analyze the consistency across operational processes and written policies and procedures. BluePeak can assist plan with development of a database to demonstrate compliance with CMS regulations and guidelines or recommend online tools to support their businesses.

Sanction Remediation

Over the past 12, BluePeak has assisted 15 plans in getting CMS sanctions remediated. BluePeak has assisted several plans who have been issued CMS intermediate sanctions with writing of the CAPs, remediation of their issues and subsequent sanction removal.  Our team has the experience with CMS’ expectations, timelines, communication and operations around these serious sanctions.

Policy and Procedure Development and Refinement

We can assist plans 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.

BluePeak is a leading national healthcare consultancy that focuses on government programs including Medicare Parts C and D, Medicaid, and Exchanges. We assist health plans, pharmacy benefit management (PBM) companies allied health companies and pharmaceutical manufacturers with regulatory, operational and compliance issues. BluePeak can analyze an organization’s processes and provide practical solutions, operational best practices and training to meet Medicare and other government program standards in all key areas.

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Experienced Medicare staff: Ready when you are!

BluePeak knows how difficult it can be for Medicare Advantage plans and TPAs to find knowledgeable resources with experience in Medicare, especially when demands increase sharply given the Medicare annual cycle. BluePeak maintains a wide variety of experienced Medicare personnel to help you with seasonal projects, operational backlogs, compliance monitoring, remediation activities, and more.

Examples of projects that BluePeak has assisted plans in 2022 include:

  • Clinical chart review by licensed clinicians
  • Call center oversight, including listening to calls for accurate classification and calibration
  • Operational support to resolve grievance backlogs and provider directory compliance
  • Pharmacy support to resolve coverage determination backlogs
  • Program area specific operational and administrative responses to a corrective action (initiated internally or externally)
  • Compliance resources to support compliance program initiatives

Whether you need one resource or many, BluePeak can quickly staff any project, train resources, track results, and deliver success.

Contact us today!