Fraud waste and abuse trend reports from CMS have included GLP-1s as potential targets. GLP-1, or glucagon-like peptide-1, is a hormone that plays a crucial role in regulating blood sugar levels. Beyond its role in diabetes management, GLP-1 has also been found to be effective in promoting weight loss. Several medications that target GLP-1 receptors have been developed, offering a promising avenue for individuals struggling with obesity.
However, it is important to remember that weight loss drugs are not covered by Medicare. Plans are being encouraged to audit for off-label use of GLP-1s. A comprehensive retrospective review process should include the following:
- Identification of GLP-1 utilization
- Confirmation of appropriate condition for GLP-1 use through medical claims and or PDE records
- Physician and patient communication
- System edits
- PDE management
- Financial process considerations
- Ongoing metrics and reporting
BluePeak is assisting plans in developing their retrospective GLP-1 review processes. BluePeak can also conduct the retrospective review on an initial or on-going basis. Contact us today to discuss a comprehensive strategy for GLP-1 management.
Inflation Reduction Act (IRA) Readiness Assessment
The IRA contains several provisions that will become effective in 2025. Plans will need to ensure readiness and compliance as CMS will likely target these requirements in Program and focused audits. BluePeak offers a comprehensive IRA Readiness Assessment. The assessment offers both process review and sampling of IRA requirements such as:
- Benefit configuration
- $2,000 MOOP
- Manufacture Discount Program
- TrOOP change/accumulation w/ EGWPs and EA plans
- Insulin max
- ACIP vaccines
- Deductible application (No IRA products contributing to deductible)
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