Course Catalog

15 minutes

This course delivers the annual training requirements as outlined by CMS, highlighting the regulatory requirements, the roles and responsibilities of the Board, and expected oversight. This training will review the importance of compliance, the seven elements of an effective compliance plan, and the role the Board plays in ensuring Plan compliance.

Upon completion of this training, you will be able to:

• Understand your role as a board member in the compliance process.
• Understand how you interact with the Compliance Committee and Compliance Officer.

30 minutes

This course delivers annual compliance training required by CMS that outlines what compliance is and how it impacts everyone in the organization. This course highlights how to report non- compliance and the responsibilities of each employee. This training assists Medicare Part C and Part D Sponsors’ employees, governing body members, and their first-tier, downstream, and related entities (FDRs) in satisfying their annual general compliance training requirements in the
regulations and sub-regulatory guidance.

Upon completion of this training, you will be able to:

• Recognize how a compliance program operates.
• Recognize how compliance program violations should be reported.

25 minutes

This course delivers annual Fraud, Waste and Abuse (FWA) training required by CMS that outlines what FWA is, regulations that govern it, how to detect and report it, as well as individual roles and responsibilities related to FWA. This training assists Medicare Part C and Part D Sponsors’ employees, governing body members, and their first-tier, downstream, and related entities (FDRs) in satisfying their annual FWA training requirements in the regulations and sub-regulatory guidance.

Upon completion of this training, you will be able to:

• Recognize FWA in the Medicare Program.
• Identify the major laws and regulations pertaining to FWA.
• Recognize potential consequences and penalties associated with violations.
• Identify methods of preventing FWA.
• Understand how to report FWA.
• Recognize how to correct FWA.

20 minutes

This course provides training on the workings of an effective Compliance Committee for health plans. This training will help you understand the structure of the Compliance Committee as well as its responsibilities in a health plan and what makes it effective.

Upon completion of this training, you will be able to:

• Understand an effective compliance program.
• Understand the potential consequences of compliance/non-compliance.
• Understand the structure of a compliance team.
• Understand the purpose and responsibilities of a compliance committee in a health plan.

30 minutes

This course delivers annual compliance training required by CMS that outlines what compliance is and how it impacts everyone in the organization. This course highlights how to report non-compliance and the responsibilities of each employee. This training assists Medicare Part C and Part D Sponsors’ employees, governing body members, and their first-tier, downstream, and related entities (FDRs) in satisfying their annual general compliance training requirements in the regulations and sub-regulatory guidance.

Upon completion of this training, you will be able to:

• Recognize how a compliance program operates.
• Recognize how compliance program violations should be reported.

60 minutes

This course is based on BluePeak’s experience on the frontline of audits and highlights common findings and how to avoid them for all program areas (CPE, FA, CDAG, ODAG, SNPCC, MMP). This training will give an overview of the audit process and timeline, discuss audit trends and common findings from recent audits, and cover tips for a successful audit.

Upon completion of this training, you will be able to:

• Demonstrate a basic understanding of the audit process and timeline.
• Understand common audit findings.
• Understand how to help your Plan achieve success in the audit process.

60 minutes – CPE
90 minutes each – FA, CDAG, ODAG, & SNP

This course is designed to help plans understand the specific changes made to the CMS audit protocols for contract year 2022.This training will help you understand what data elements are required on each universe, and how they have changed since the previous contract year. This information can be used to assist plans in mapping and pulling data within their systems to ensure universes are accurate and will pass data integrity.

Upon completion of each program area training, you will be able to:

• Understand the universes associated with that program area.
• Understand what data elements have changed for contract year 2023.
• Understand sample selection criteria.
• Develop a process to review universe changes and updates within your organization.

15 minutes 

This course covers the CMS guidance cycle and best practices for guidance review, dissemination, and action. This training provides an overview of how to effectively manage guidance monitoring for health plan compliance departments.

Upon completion of this training, you will be able to:

• Understand the importance of managing regulatory guidance.
• Understand the relevant sources of regulatory guidance.
• Understand how to handle regulatory guidance once issued.

60 minutes 

This course covers the CMS Compliance Program requirements. This training will go over what constitutes an effective compliance program, how to evaluate effectiveness, the CMS audit process, and best practices for compliance and Compliance Program Effectiveness (CPE).

Upon completion of this training, you will be able to:

• Understand CMS Compliance program requirements.
• Understand the components of a Compliance audit.
• Determine the effectiveness of your compliance program
• Implement best practices for compliance and CPE.

30 minutes 

This course teaches compliance staff the process for building a robust Risk Assessment. This training will help you understand what a Risk Assessment is and why it is important. This training will also show you how to conduct and maintain an effective Medicare Risk Assessment.

Upon completion of this training, you will be able to:

• Understand what a Risk Assessment is and why it is important.
• Understand how to conduct an effective Medicare Risk Assessment.
• Understand how to maintain an effective Medicare Risk Assessment.

30 minutes 

This course covers what CMS expects from plans when overseeing their delegates.
This training will help you understand what delegation oversight is, key regulations and requirements that apply to delegation, and oversight functions, including risk assessments and delegation audits.

Upon completion of this training, you will be able to:

• Understand what delegation oversight is.
• Understand key regulations and requirements that apply to delegation.
• Understand oversight functions, including risk assessments and delegation audits.
• Recognize common audit findings related to call logs.

30 minutes 

This course teaches compliance staff the process for building an audit and monitoring plan from your Risk Assessment. This training will help you understand what an Audit and Monitoring Workplan is, how to develop one, as well as how to maintain it.

Upon completion of this training, you will be able to:

• Understand what an Audit and Monitoring Workplan is and why it is important.
• Understand how to develop and maintain a robust Audit and Monitoring Workplan.
• Learn the steps to take after developing the Audit and Monitoring Workplan.

45 minutes 

This course covers the Seven Elements of an Effective Compliance Program. This training will discuss each of the different elements and why they are important, potential compliance issues, and best practices and tips for running a successful compliance program.

Upon completion of this training, you will be able to:

• Understand each of the Seven Elements of an Effective Compliance Program and why they are important.
• Identify potential compliance issues.
• Implement best practices and tips for a successful compliance program.

60 minutes 

This course teaches health plans what to do after an audit to ensure that corrective actions are implemented and effective. This training will help you understand what a Corrective Action Plan (CAP) is, how to identify and describe issues in need of correction, how to determine Member Impact, how to identify Root Causes, how to effectively communicate Corrective Action Plans to the appropriate parties, timeframes for Corrective Action Plans, proper remediation documentation, and how to close a Corrective Action Plan.

Upon completion of this training, you will be able to:

• Understand what a Corrective Action Plan is.
• Describe the components of a Corrective Action Plan.
• Identify and describe issues in need of Corrective Action.
• Determine Member Impact.
• Determine Root Causes.
• Communicate Corrective Action Plans to the appropriate parties.
• Understand timeframes for Corrective Action Plans.
• Understand how to properly document remediation.
• Understand how to close a Corrective Action Plan.

30 minutes 

This course dives into how to perform a root cause analysis. This training will help you understand what a root cause is and the steps needed to complete an effective root cause analysis. The course will also focus on how to use the findings from the root cause analysis to implement change within your organization.

Upon completion of this training, you will be able to:

• Identify the need for a root cause analysis.
• Understand the importance of performing a root cause analysis.
• Conduct a root cause analysis.
• Implement and monitor change based on root cause analysis findings.

30 minutes 

This course covers the audit protocols and process for Medicare and Medicaid Demonstration Plans.

Upon completion of this training, you will be able to:

• Identify the need for a root cause analysis.
• Understand the importance of performing a root cause analysis.
• Conduct a root cause analysis.
• Implement and monitor change based on root cause analysis findings.

30 minutes 

This course is designed based on BluePeak’s experience with preparing plans for CMS program audits. This training will review the types of audits Medicare Advantage Plans are subject to, ways to prepare your organization for audits, and best practices and tips for successful audits.

Upon completion of this training, you will be able to:

• Understand the importance of preparing your organization for audits.
• Understand the different types of audits your organization is subject to.
• Implement best practices to ensure audit readiness.
• Develop a program to identify compliance risks.

15 minutes 

This course covers the elements of a One-Third Financial Audit and what to monitor to ensure readiness. This training will go over the background of a One-Third Financial Audit, the audit process at a high level, the audit timeline, your Prescription Benefit Managers (PBM) role in a 1/3 financial audit, the documentation requested from an auditor, what happens after an audit, and best practices and tips for success.

Upon completion of this training, you will be able to:

• Understand what a One-Third Financial Audit is.
• Understand how to navigate successfully through an audit.

45 minutes 

This course covers the Centers for Medicare and Medicaid Services (CMS) enforcement actions in recent history, a look at how compliance is measured, and actions plans can take to mitigate non-compliance.

Upon completion of this training, you will be able to:

• Understand CMS compliance enforcement actions and facts regarding recent compliance actions and civil monetary penalties.
• Understand compliance and enforcement actions that result in negative impacts to plans.
• Know how compliance is measured by CMS.
• Have action items to mitigate non-compliance.

40 minutes 

This course outlines what a Risk Adjustment Data Validation (RADV) audit is and what a plan can do to prepare for the audit. This training will help you understand what a RADV audit is, why it is important, how plans are chosen, what is included in the audit, how it works, RAPS background, operational challenges during the audit, and how plans can mitigate risk.

Upon completion of this training, you will be able to:

• Understand what a RADV audit is and why it is important.
• Understand how plans are chosen.
• Understand what is included in the audit.
• Understand how the audit works.
• Understand RAPS background.
• Understand operational challenges during the audit.
• Understand how plans can mitigate risk.

30 minutes 

This course provides a general overview of risk adjustments, processes, chart reviews and proper oversight. This training also covers the timeline for Risk Adjustment payments and the impact they have on plans.

Upon completion of this training, you will be able to:

• Understand CMS Risk Adjustments process and why it is important to MA and commercial plans.
• Tools to develop proper oversight.
• Understand the timeline of Risk Adjustment processes and the impact it has on plans.

30 minutes

This course reviews plan requirements, policies, and procedures related to Medicare Organization Determinations. This training will review what a coverage determination is used for, who can file one, and how they must be handled.

Upon completion of this training, you will be able to:

• Define an organization determination.
• Recognize when an organization determination is being requested.
• Understand who can file organization determinations.
• Understand the timeframes in which organization determinations must be processed

30 minutes

This course reviews plan requirements, policies, and procedures related to Medicare Part C Appeals and Grievances. This training will review what an appeal and grievance are related to Medicare Part C, what they are used for, who can file one, and how they must be handled.

Upon completion of this training, you will be able to:

• Define an appeal and grievance.
• Recognize when an appeal or grievance is being requested.
• Understand who can file appeals and grievances.
• Understand the timeframes in which appeal or grievance must be processed.

20 minutes

This course covers the critical components of an effective Pharmacy Benefit Manager (PBM) oversight plan. This training will review the Medicare Part D definitions related to oversight and monitoring of Pharmacy Benefit Managers or PBMs, Medicare Compliance Program oversight requirements, services delegated to PBMs, and PBM oversight and monitoring.

Upon completion of this training, you will be able to:

• Identify and define common terms for monitoring and oversight of pharmacy benefit managers.
• Recognize and understand Medicare compliance program requirements for pharmacy benefit management oversight.
• Describe the different oversight monitoring processes for delegated services to pharmacy benefit managers.

30 minutes

This course reviews plan requirements, policies, and procedures related to Medicare Coverage Determinations. In this introductory course, we will be reviewing Medicare Part D coverage determinations’ definitions, Policies and Procedures, Requests, timeframes, receipt of requests and processing, notification and dismissals.

Upon completion of this training, you will be able to:

• Identify and define Medicare Part D coverage determinations.
• Understand Part D coverage determination requirements.

30 minutes

This course reviews plan requirements, policies, and procedures related to Medicare Part D Appeals and Grievances. This training will review what an appeal and grievance are related to Medicare Part D, what they are used for, who can file one, and how they must be handled.

Upon completion of this training, you will be able to:

• Identify and define Medicare Part D appeal and grievance.
• Recognize and understand Part D appeal requirements.
• Describe the different levels of Part D appeals.
• Recognize and understand Part D grievances and grievance requirements.

60 minutes

This course outlines how to identify various requests that may come into your call center, pointers and techniques for call center staff to use, and regulatory requirements that apply to each of the identified requests. This training will provide you with the necessary background and guidance to effectively manage different call types and resolve member questions and concerns on the first call as often as possible.

Upon completion of this training, you will be able to:

• Identify different call types, including grievances.
• Demonstrate an understanding of the importance of proper classification of call types.
• Document complete and accurate call summaries.
• Implement strategies for obtaining First Call Resolution consistently.

30 minutes

This course highlights the importance of call log reviews for audit success and provides suggestions on call center oversight. This training will help you understand what a call log is, know how to pull a call log, understand effective internal monitoring, and familiarize you with common findings in call log reviews.

Upon completion of this training, you will be able to:

• Demonstrate an understanding of call logs.
• Implement strategies for pulling call log universes.
• Develop an internal monitoring program.
• Recognize common audit findings related to call logs.

60 minutes

This course focuses on the required operational requirements within a call center and provides suggestions on best practices to meet them. Call center leadership will gain an understanding of key operational metrics such as average speed of answer, hold time, and accuracy. The course will also review call monitoring initiatives performed by CMS and how to prepare the teams for success.

Upon completion of this training, you will be able to:

• Demonstrate an understanding of the importance of meeting call center operational metrics and the impact to the plan
• Identify the different monitoring activities performed by CMS and implement best practices to prepare
• Implement strategies for successful call center practices such as documentation and call classification
• Recognize key metrics to monitoring under an internal monitoring program

30 minutes

This course will provide an overview of the CMS Star rating system, including why it is important for plans and how Star ratings are calculated. This course will also include in-depth details behind how and what CMS measures plans on.

Upon completion of this training, you will be able to:

• Understand CMS Start ratings program
• Know what the five-star quality rating is and why plans are measured by it.
• Identify Part C and Part D Star measures and how ratings are calculated.
• Review best practices in a Star program.

30 minutes

This course covers everything you need to know about EGWP plans, from product development to operational differences compared to MA plans.

Upon completion of this training, you will be able to:

• Understand what and EGWP plan is and how it is different from MA plans.
• Understand how an EGWP works.
• Know what is waived and how plans can be developed to meet specific employer needs.

25 minutes

This course covers how to develop and review marketing materials and member communication materials for accuracy in accordance with current guidance. This training will review the difference between marketing and communication, Medicare guidelines, model materials, mapping your Medicare bid filing to materials, and quality review.

Upon completion of this training, you will be able to:

• Demonstrate an understanding of communication and marketing materials.
• Implement strategies for creating model materials.
• Recognize the relationship between Plan benefits and model materials.
• Develop an internal quality review program for materials.

30 minutes

This is an introductory course to Medicare enrollment requirements. The training will review enrollment eligibility, election periods, and CMS processing procedures. Additionally, the course will walk through what to do upon a beneficiary disenrollment and what activities plans are required to complete post enrollment.

Upon completion of this training, you will be able to:

• Identify the different Medicare election periods
• Understand how election periods impact effective dates of enrollments and disenrollments
• Demonstrate an understanding of enrollment procedures
• Recognize the importance of post enrollment and enrollee notification requirements

45 minutes

This 45-minute training includes key milestones of the audit, the four phases of the PACE audit (Audit Engagement and Data Submission: Phase I, Audit Field Work: Phase II, Audit Analysis & Reporting: Phase III, and Audit CAPs and Audit Close-Out: Phase IV), and includes tips for a successful audit.

Upon completion of this training, you will be able to:

• Understand of the current audit protocols
• Identify what to look for and how to conduct a quality review of documentation and universes
• Navigate cases and documentation with CMS to present your information in a way that is clear, precise and easy for auditors to understand
• Determine who should participate in an onsite audit, how to present during the onsite audit, and how to handle questions and observations from the auditors
• Recognize post audit activities and timelines and how best to rebut a finding or condition or respond to requests from CMS such as corrective action plans