Medicare Part C and Medical Claims
Part C End-to-End Part D Claims Processing Audit
Processing claims can be complicated but we are here to help. BluePeak can review claims to ensure providers are being reimbursed accurately and member cost shares match your CMS bid. We can target a variety of scenarios including contractual pricing, denials, high cost, non-contracted provider, and timeliness. Our approach will review policies and procedures, training documentation, and desk-level procedures to ensure adherence with MS guidance.
Case Management
Is your Case Management program providing the most cost effective, efficient management of your members? BluePeak can help review your policies and procedures, stratification and identification of those members, evaluate staffing and make recommendations to make your program successful.
Plan Performance in Quality (Stars/HEDIS/Gaps in Care)
NCQA updates protocols annually in accordance with changes from CMS and refinements in the factor level details. Now CMS requires a plan receive a 50% or greater score in each element, regardless of passing in the overall score for the MOC to pass without “cure”. BluePeak can help you review your MOC and make recommendations and edits to meet all requirements and do a preliminary scoring before submission to NCQA to ensure you have addressed all areas before submission to NCQA!
CMS Star Strategies and Expertise
At BluePeak, we understand that every health plan has its own unique challenges and opportunities. That’s why we specialize in crafting tailored strategies that align with your plan’s specific needs. Our expert team conducts a thorough assessment of your current Medicare Stars program, providing targeted recommendations designed to enhance performance across all domains. By integrating quality into your health plan operations, we help you achieve your Stars goals, ensuring your organization excels in delivering exceptional care and service. Discover how BluePeak can elevate your Medicare Stars program to new heights.
Model of Care (MOC) Review and Scoring
Before you submit your MOC to the National Committee for Quality Assurance (NCQA) let BluePeak’s experienced Subject Matter Experts (SMEs) discuss with your stakeholders and propose changes and improvements to your program. Our team will review and complete an initial scoring of your drafted MOC to ensure new and changed requirements have been accounted for. We will provide coaching to your team and offer recommendations to consider for your MOC prior to submission in an effort to help you achieve higher scores in all elements.
Utilization Management
Whether you process UM requests internally or delegate them to a vendor, oversight of the decision-making processes is critical. BluePeak is here to review policies, procedures, and targeted samples for proper and timeline notifications, clinical appropriateness, and overall compliance.
Our Services
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.