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Medicare Part D and Pharma

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Part D End-to-End Part D Claims Processing Audit

Medicare Part D claims are under more scrutiny than ever. Let BluePeak help you identify and remediate common audit findings such as unbreakable packages, Part B vs Part D determinations, transition, protected class drugs, and utilization management restrictions. Our testing approach supports your team from formulary analysis through paid and rejected claims analysis and monitoring.

Pharmaceutical Analytics and Services

BluePeak provides strategy and services specific to pharmaceutical manufacturers’ needs. We are uniquely qualified to provide industry expertise to pharmaceutical manufacturers.

  • Knowledge in the health plan and employer client marketplace.
  • Knowledge and in-depth experience with CMS policy and ongoing industry challenges.
  • Experience delivering focused training sessions on the complex pharmacy benefits for public and private insurance on the complex Medicare benefit and program
  • Thought leaders in industry groups

Medication Therapy Management (MTM)

Targeting members for participation in your MTM program is required by CMS. BluePeak can assist with development of your MTM program eligibility, including drug and diagnosis information. We will review your eligibility and claims files to ensure proper identification of eligible members, disenrollment when appropriate, and confirm if your program implementation is compliant. Our subject matter experts are here to assist you with a best-in-class MTM program.

PBM Audit

PBM audits are an integral part of a plan’s overall risk assessment strategy and are also essential in ensuring that financial and contractual terms are being administered as intended. BluePeak can perform comprehensive or targeted PBM audits for all lines of business. Our robust, comprehensive PBM Audit includes:

  • Financial Audit
  • Formulary Administration Audit
  • Benefit Design Audit
  • Rebate Administration Audit
  • Medicare Audit Review

Formulary Management Strategies

BluePeak understands the importance of formulary management in driving clinical and financial outcomes. Our multi-disciplinary team can design and manage formulary solutions that align with your organization’s unique goals.

PBM Implementations/Transitions

BluePeak can assist with PBM implementations and transitions.  Our team will work both your team, your existing PBM, and your incoming PBM to ensure a successful go-live. BluePeak offers a wide array of implementation and transition support services to help ensure that a vendor transition is smooth and successful.

PBM RFP Development, Review, and Contracting

BluePeak offers Plans an industry-leading End-to-End PBM Procurement Process designed by former PBM Underwriters and Professionals. BluePeak’s procurement process is designed around optimizing the final PBM service agreement and leads to BETTER transparency & PBM Partnerships. Our partnerships with large, sophisticated clients has given us unrivaled experience in supporting efforts to
carve-in, carve-out and/or insource nearly every element of the PBM business model. Plans can select the complete end-to-end process or we can customize a project to support any phase along the way.

Prescription Drug Event Management

Let BluePeak Advisors Monitor, Manage and Maximize your PDE data with our PDE3 service. Our PDE experts will work with your team to validate the accuracy of your PDE records and CMS payments, while reducing your PDE rejection rate.

Monitor

  • Audit PDE records for payment accuracy
  • Maintain audit logs and assist with corrections

Manage

  • Reconcile monthly CMS financial reports
  • Validate quarterly Coverage Gap Discount payments
  • Perform plan-specific PDE financial outputs

Maximize

  • Collaborate to maximize PDE acceptance rate to optimize CMS payments
  • Mitigate future PDE rejections
  • Generate monthly PDE reports

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!