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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!

STAR Rating Projection and Gap Analysis

BluePeak can help you prioritize your resources to get the largest improvements for your dollar, as well as assist with project planning and strategies to enhance your Star ratings across all of your Part D measures. We can share best practices across the 4 and 5 Star plans that make them successful.

Model of Care (MOC) Review and Scoring

Before you submit your MOC to the National Committee for Quality Assurance (NVQA) 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.

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!