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Fraud, Waste and Abuse (FWA) Support

The BluePeak FWA Program assessment 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.

Our approach is to work collaboratively, allowing BluePeak to offer our clients a solution for reducing FWA that is comprehensive, timely, efficient and in compliance with the highest industry standards, those provided by CMS.

Compliance Program Implementation

BluePeak’s Compliance experts can build and help you implement a Compliance Program customized to your organization that meets CMS and other regulatory requirements.  Whether you are a new Plan or your Plan has been in existence, we will evaluate your organization’s structure and design and implement a comprehensive and effective Medicare Compliance Program.  We will ensure your Compliance Program identifies areas of risk, has an oversight plan that includes internal and delegated operations, and has a strong issue resolution and corrective action plan (CAP) process.  Your customized program can also include the development of your Code of Conduct, Compliance Plan and processes for CMS required training, Exclusions checks and vendor oversight.

Comprehensive Oversight and Monitoring Programs

Every effective Compliance Program has robust oversight and monitoring programs to identify areas of risk and deficiencies in its internal operations as well as those that have been delegated externally to vendors.  BluePeak’s subject matter experts can evaluate your organization’s structure and build a customized and comprehensive oversight program that includes a CMS required risk assessment and monitoring and auditing plans.  We can help develop and implement tools and dashboards that can be used to track and trend metrics and be utilized as evidence of the effectiveness of your program.

No matter the size of your Compliance Program, we can work with your teams to build a program that meets CMS requirements and is effective in identifying areas of risk within your organization.

Vendor (FDR) and Internal Oversight and Monitoring Programs

One of the major reasons plans 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.

CMS is turning their attention towards plan delegated vendors and how well that plans are overseeing and managing their vendors, paying particular attention to PBMs, print, clinical and enrollment vendors. BluePeak can review your vendor oversight programs, make suggestions for enhancements and assist with implementation of these new programs. BluePeak can also review your delegated vendors, and assist with operational assessments, vendor audits and ultimately new vendor RFPs if needed.

Corrective Action Plans

All Plans face issues with internal operations and their delegated entities.  How effectively they address those issues is what sets Plans apart in the eyes of CMS.  Medicare Plans must have robust, timely and effective issue resolution and CAP programs to address deficiencies.  BluePeak can develop a customized CAP program or evaluate your existing CAP program and identify gaps and areas that need strengthening.  We can work with your teams to ensure your CAP program is effective, contains thorough root cause analysis and strong corrective actions to address the underlying defects and prevent future reoccurrence.

We will also ensure that your CAP program is thoroughly documented so that you can provide evidence to CMS when your Plan is selected for a Compliance Program Effectiveness (CPE) Audit.

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!