Physician Payments Sunshine Act: CMS Dispute Resolution Call Reveals Complexities With Open Payments System

 

The Dispute Resolution process of the Physician Payments Sunshine Act takes place in the time between when pharmaceutical and device manufacturers submit their payment data to the Centers for Medicare and Medicaid Services (CMS) and when the data becomes public on September 30, 2013. During this time, physicians and teaching hospitals can theoretically register in Open Payments, review any transactions listed under their names, and dispute any inaccuracies with the manufacturers.

Yesterday, CMS held a webinar discussing the process physicians and teaching hospitals must go through in order to review their data. The 90 minute, 91-slide presentation walked stakeholders through the process of registration with Open Payments and the dispute process. The number of steps involved to review data may serve as a deterrent for already busy physicians simply interested in finding out what companies have recorded about them. However, with important privacy concerns, the need to verify users’ identity, and the inherent complexity of Open Payments, CMS’ slides may be essential for working through the process.

The presentation shined light on a number of complexities with the process for physicians and hospitals to be aware of.

Registration

Physicians and teaching hospitals should register as soon as possible. You must first go through EIDM Identify Verification, which many doctors have already done, before registering with Open Payments. Physicians and teaching hospitals have been able to register with Open Payments since July 14, 2014. Physicians will be vetted using profile information including: business address, National Provider Identifier (NPI), Drug Enforcement Agency (DEA) number, and state license information.

CMS notes that the vetting process will “take roughly 24 hours,” and encourages users to “provide as much information as possible, as more information speeds vetting and ensures all records associated with you will be matched to your profile.” Vetting must be successful in order for the physician to perform actions within the Open Payments system before the authorized representative can do anything in the Open Payments system. Registration must be completed in one sitting, and CMS forewarned users that they cannot use outside browser functions once they are in the Open Payments system.

Once a physician registers, they are able to nominate “authorized representatives” to fulfill a variety of roles, depending on what the physician selects. Authorized representatives may have one of three access levels: (1) Read-Only, which is the default, where representatives are able to see a physician’s “My Profile” and record information; (2) Modify Profile, where the representative can edit or enter a physician’s profile information (NPI, license, specialties, etc.); and (3) Dispute Records, where the representative can dispute records related to the physician submitted by reporting entities. Access levels are separate; for example: having “dispute records” access does not automatically include “modify profile” access, or vice versa.

Teaching hospitals may also register in the Open Payments system if they want to review and dispute information reported about the hospital by reporting entities prior to its publication. Teaching hospitals must be selected from a prepopulated list in Open Payments. The “authorized official” of the hospital must register with Open Payments, and can then nominate other individuals as authorized representatives and authorized officials. Teaching hospitals can have up to 10 individuals associated with them in Open Payments, including five authorized officials.

Dispute Resolution:

An ideal dispute resolution scenario is put forth by CMS in the image below:

Before getting to the point of disputes, however, we have heard that CMS’ system has made it difficult for physicians and teaching hospitals to get to the point of being able to meaningfully review their data in the first place. One commenter mentioned that the tables of data were difficult to manipulate, and occasionally the server would kick her back a number of pages without saving her data. Anohter commented on the difficulty in trying to print the data.  The CMS personel on the call recomended that you cut and paste the information from the Open Payments review site into Excell or use the print screen fuction.  Neither alternative sounds very productive for teaching hosptials and large physician practices.

If the system works according to plan, users have a 45-day potential correction window. If a physician or teaching hospital disputes a record within the 45-day period (7/14 – 8/27/2014), and if the dispute status of the record on 9/11/2014 is:

– Resolved, then the corrected record is published as non-disputed on September 30, 2014.

– Not resolved, then the originally reported record is published as disputed in September 30, 2014.

Physicians and teaching hospitals receive email notifications if a record they disputed is modified by the company, or if the company identifies the dispute was resolved without having changed the record.

CMS repeated many times that they “will not mediate the dispute resolution process between a physician and a reporting entity.” In the cases where a dispute cannot be resolved, the latest, attested-to data submitted by the reporting entity will be published and identified as under dispute.

An interesting situation could thus arise where the physician or teaching hospital believes that a dispute with a status of “Resolved” has not been sufficiently resolved. Their only recourse is initiating another dispute on the same record. Companies can unilaterally dismiss disputes, so it would seem as though companies and physicians would be racing to the finish line when CMS publishes the data to see whether their transfer of value is marked “disputed” or not. CMS reaffirmed that the number of disputes would “advise the auditing process,” so it may be in companies’ best interests to avoid them when possible. 

Corrections made after the initial 45-day review and 15 day dispute period will not be reflected in the Sept. 2014 public posting. Data corrections made by reporting entities may be made at any time and the corrections will be updated in the next publication of the data. “They, and any subsequent corrections to resolve the disputes would be reflected in the next annual publication of the data, anticipate in early 2015,” CMS notes in their slides. 

Physicians and teaching hospitals may review and affirm records associated with them. Affirming is optional, and means that the physician or teaching hospital confirms that the information captured in the record is correct. Records not affirmed by the physician or teaching hospital will still be published on the public-facing website. Physicians may also withdraw disputes once they have been filed. 

CMS’ current timeline: