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Medicare Operations Expertise

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Call Center Assessment & End-to-End Monitoring

While this is no longer a requirement, CMS can audit Call Logs as part of CPE Audits. The BluePeak End-to-End Call Log Review can help you identify and correct misclassification issues that might be detected in a program audit.

  1. Part C and/or Part D Call Log Review
  2. Call Recording Monitoring
  3. Training and Process Improvement

Credentialing Audits and Policy Reviews

BluePeak conducts credentialing audits and credentialing policy reviews of an organization’s delegate(s), to assure that they are compliant with all Federal regulations as it pertains to credentialing under the Affordable Care Act (ACA) program, National Committee for Quality Assurance (NCQA) and CMS as appropriate.


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.

Health Care Policy Analysis and Application

BluePeak understands the burden that daily HPMS memos can place on plans, especially small to midsize plans, that may not have the resources to monitor and interpret daily issues. BluePeak monitors, analyzes, and summarizes key Medicare legislation, 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 them develop and implement practical and actionable steps so Medicare plan sponsor clients can proactively address policy-driven operational challenges and business opportunities head-on.

Interim Staffing and Permanent Staffing Assistance

BluePeak can provide plan experienced compliance and operational professionals to assist your staff on 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.

Medicare Sales & Marketing Services

BluePeak’s comprehensive Medicare Annual Enrollment Period (AEP) Support from pre-AEP, during and post AEP including:

  • Sales & Marketing Oversight Assessments
  • Bid – PBP Quality Reviews
  • Member Material Development and/or Review
  • Broker Assessments
  • Sales Training Development Support
  • AEP Agent Secret Shopping Reviews

Medicare Applications and Implementations

Are you new to the Medicare market? BluePeak has worked with many plans to implement a new product for an organization that is not familiar with Medicare. We will build a project plan, organize and hire internal staff, develop budgets, project manage the implementation, drive teams to completion of tasks and support CMS communications. Interested in starting a new MA or MA-PD 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.

Product Strategy

Not sure if it is still a good time to get into the Medicare market? BluePeak can support plans with strategic and financial advice to make those tough decisions about what types of products, and when to enter the market.

Medicare Bid Development and PBP Review

It’s important that the Plan Benefit Package (PBP) you submit accurately reflects the intended benefit design described and supported by the bid pricing tool. BluePeak has experienced reviewers who have a strong understanding of the bid data entry process and can review the PBP for accuracy, implementation, and compliance. BluePeak reviews for alignment of PBP data that reside in several areas, optional (either mandatory or supplemental) benefits vs. core Medicare covered benefits, described throughout the PBP data.  BluePeak establishes communication with key stakeholders to ensure the intended benefit design is submitted. We can help establish processes for best practices and relieve some of the stress associated with bid submission and operational implementation.

Medicare Marketing Material Review

BluePeak has a team of experts that are trained and experienced in developing member materials, reviewing materials for common (and uncommon) errors. BluePeak incorporates best practices in every step of the process including comparing materials to the PBP and all current regulatory references. BluePeak’s materials support process includes work on over 300 member material documents annually.

Provider Directory Review

BluePeak conducts a Provider Directory review of the Plan’s online searchable provider directory and conducts outbound calls to providers to validate the information found in the online provider directory is accurate.

Our audits adhere to the cited methodology by CMS which includes:

  • Evaluation of the same provider types and sample size as CMS does for the MAPD contract selected
  • Samples are chosen randomly across the service areas.
  • Each provider will be reviewed for a specific set of 10 elements

Outbound calls are made to attempt verification of information found online; may include calls to multiple locations to verify information.

BluePeak uses the same scoring methodology for deficiencies that CMS uses for their pilot verifications with weighting of deficiencies from 0-3 and will provide an individual provider score as well as an aggregate score.

Risk Adjustment Operational Assessment & Comparative Analysis

BluePeak risk adjustment operational assessments are designed to prepare plans for risk adjustment audits and boost operational performance.

  • Achieve risk adjustment audit readiness in as little as 12 weeks
  • Assessment can be customized to fit the specific needs of the plan

OIG and GSA Background Checks

BluePeak understands that the top deficiencies for plans with OIG and GSA background checks are no monthly checks, do not include temps, Board of Directors or consultants, do not have a smooth process for accountability and do not do sufficient oversight and monitoring.

Let BluePeak administer this service compliantly for your plan with our efficient process, great communication, monthly reports, and oversight and monitoring processes

Third Party Marketing Oversight

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.

Agent and Broker Oversight

Need oversight of your field marketing organizations? Often plans delegate activities to their brokers or general agencies due to lack of resources. Oversight is a critical component to the success of your FDR and compliance program. BluePeak understands the nuances of ensuring each delegate is performing sanction reviews, maintaining licensure, training, and appointment documentation, as well as collecting and providing accurate, timely responses for follow-up inquiries, such as scope of appointment or marketing material misrepresentation complaints. Let us help you conduct your oversight before you find yourself buried in another AEP cycle.

Secret Shopping and Tele-Sales Recorded Call Review for AEP & OEP

BluePeak performs live and recorded reviews to evaluate the compliance of the prospective sales calls. BluePeak representatives will conduct mock prospective member calls. During the call they will request plan information, review in-network providers and confirm formulary covered medications. The secret shopper will test hold times, TTY, language line, agent knowledge of the plan benefits, as well as providing you feedback on agent soft skills, all while ensuring your contracted agents are following the CMS marketing guidelines.

Staff Training Programs

BluePeak offers online and live instructor-led training, anytime, anywhere; in-person, webinar, testing included. We can provide one of already curated programs or customize a program specific to you organization.

BluePeak also offers online training platform through BluePeak University.

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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