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BluePeak understands the specialty market of All-Inclusive Care for the Elderly (PACE) plans and the importance of delivering of health care services to participants enrolled in PACE Organization with remaining compliant with CMS regulatory requirements associated with access to services, drugs, and other protections. Since CMS has increased its focus on audits of PACE plans, we anticipate the growing regulatory scrutiny that some PACE plans are facing–scrutiny and even receiving sanctions and civil money penalties (CMPs) for non-compliance. PACE audits evaluate the delivery of health care services provided to participants enrolled in PACE Organizations. It is critical for plans to have compliant and effective procedures in place to improve the efficiency and effectiveness of the audit process.

BluePeak assists PACE Plans with Quality Review, PACE Audit Protocols, Part D regulatory guidance and PDE/DIR support, PACE Audit Process and Case Review preparations.

BluePeak’s team of subject matter experts of Registered Nurses (RNs) provide extensive nursing facility clinical consulting. Our RN Clinical Compliance Consultants have advanced knowledge of current regulatory requirements, best practices, standards, and the Long-Term Care Survey Process (LTCSP). Our team have significant experience working in nursing homes and/or with nursing homes from a payor perspective.

Nursing Facility Clinical Consultant capabilities include:

  • Mock survey and survey preparation
  • Clinical operational assessment to identify compliance risk, opportunities for process efficiencies, and scalable best practices
    • Clinical skills assessment
    • Chart audits
    • Policy and procedures
    • Clinical protocols
    • Internal monitoring and controls
  • Quality Improvement Process Assessment
  • Develop Monitoring Tools
  • Assist with development and implementation of Corrective Actions in response to
    • State Audits
    • Mock Audits
    • Internal Audits
  • Provide education and training
    • Onboarding for clinical staff
    • Targeted in-service training
      • MDS review and training
      • PPS enhancement
      • Sentinel Events to include documentation review and how to avoid

BluePeak helps plans prepare for audits of their FFE Plan. BluePeak’s mock audits are conducted in a manner which simulates a real audit from The Centers for Medicare and Medicaid Services (CMS) and The Center for Consumer Information and Insurance Oversight (CCIIO). The mock audit will include a formal audit announcement, set submission timeframes, an entrance and exit conference, as well as documentation review and case sampling of HICS Casework, Enrollments, Terminations and Renewal-Discontinuation Letters and more.

BluePeak also supports Qualified Health Plans (QHPs) that have received their FFE audit notice with end-to-end audit support or customized support as needed.  Click the link to learn more about how plans can optimize FFE Compliance with BluePeak’s expert audit insight.

Medicaid (all or state(s) specific)

BluePeak is familiar with the nuances between states and their administration of the Medicaid program. We have also observed the growing alignment between Medicaid, Medicare and private coverage plans, as a result of the Medicaid and Children’s Health Insurance Program (CHIP) Managed Care Final Rule and the Medicare-Medicaid Plans (MMPs). Timeframes and processes for member notices, coverage decisions, grievances, encounter data reporting, provider networks and directories, transition of care, quality rating systems, records retention, etc. will be consistent across the various managed care plans by 2021. As a result, we are able to provide many of our Medicare services, such as mock audit and audit support, marketing material review, operational assessments, and others, to our Medicaid clients.

Employer Group Waiver Plans (EGWPs)

BluePeak understands the unique needs of Employer Group Waiver Plans (EGWPs) operational similarities and more importantly the differences involved in administering EGWPs. BluePeak offers customized solutions for EGWP Plans, direct contract EGWPs, and employer groups that contract with EGWP administrators.

Interested in starting a new EGWP plan or doing a service area expansion? BluePeak staff has supported plans in completing many successful applications. We understand what is needed and what CMS’ expectations are with the new regulations and guidance.

Qualified Health Plans

BluePeak understands the unique and additional measures that a Quality Health Plan (QHP) faces. We offer audits and support for organizations required to submit data to the Centers for Medicare & Medicaid Services (CMS) under the Affordable Care Act (ACA). We have experience multiple FFE compliance audits including Medical Loss Ratio (MLR), Advance Payments of Premium Tax Credit (APTC) and Market Conduct exams.

Our audit is conducted simulates as closely as possible a real audit from The Centers for Medicare and Medicaid Services (CMS) and The Center for Consumer Information and Insurance Oversight (CCIIO).  By utilizing a risk-based audit approach high risk areas that have historically been the focus of CMS and CCIIO auditors will be emphasized.

Proactive Clinical Monitoring

Our in-house clinicians ensure appropriate drug use, monitor high-cost claims, and apply competitive Pharmacy Industry strategies.

  • Review high-cost claims to ensure appropriate utilization management
  • Provide commentary to clients on major PBM formulary changes
  • Monitor pipeline and industry updates
  • Consult on the value of PBM offered programs (i.e. Opioid use management)
  • Concentrated focus on Specialty pharmacy management including Medical Specialty
  • Vendor oversight and scrutiny as it relates to rebates, clinical programs and contract compliance

BluePeak Advantage Program

The BluePeak ADVANTAGE™ Program is designed to help organizations optimize their Medicare program. It creates an enhanced concierge service model that will provide a lifeline of support, while also creating savings for multiple projects.

Our membership levels range from Essential services and products to Elite services. Each level provides progressively more support and offerings as well as access to full range of BluePeak expertise with all products and program areas. The program creates access to thought-leadership information, regulatory summarizations and personalized information to address any challenges the organization may be facing.

Quality Assurance Claims Testing

BluePeak can provide a comprehensive approach to reviewing your current enrollment operations.  Enrollment transaction codes require action and response which can be cumbersome to plans. We will review your enrollment processing including disenrollment, late enrollment penalty, low-income subsidy, and coordination of benefits for accuracy and timeliness.  We are here to guide you through enrollment operations to ensure adherence to CMS requirements and appropriate reporting.

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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