Open Payments Dispute Resolution Call Reveals Tension Between Manufacturers and Covered Recipients

On Wednesday afternoon, the Centers for Medicare and Medicaid Services (CMS) held a teleconference for physicians and teaching hospitals to help them through the process of reviewing their Open Payments data and potentially disputing their information. Notably, CMS has streamlined their teaching tools for physicians to a manageable 38-page PowerPoint (from over a hundred pages before, see p. 200). CMS re-iterated their position that they will not be involved in mediating disputes. However, “CMS will monitor disputes and resolutions to inform the program auditing process,” they stated. “How many disputes are initiated as well as the volume of unresolved disputes,” will be of particular interest to the government. 

Physicians, teaching hospitals, principal investigators, or their agents may review records, affirm records, initiate disputes, or withdraw disputes on the Open Payments website. But even if covered recipients do not check on their data and affirm their records, the payment data will still be published regardless of whether recipients ever log in to the Open Payments system. Thus, manufacturers have the final say regarding disputes, but are kept in check by the fact that physicians can continually dispute payments after manufacturers remove the disputes. This seems to encourage an open dialogue between the two parties to collaborate and work through this process.

A troublesome point for physicians and teaching hospitals that consistently came up during the call is the lack of context or consistent reporting of the “Nature of Payments” categories by manufacturers. For example, one caller articulated the process of reviewing payments for physicians who received a device or instrument loan. “One manufacturer reported it as a gift, some as space rental, and some as consulting payments,” the caller noted. Indeed, it is up to the manufacturer to determine the nature of payment of certain transfers of value. For compliance personnel working in hospitals attempting to verify whether or not these payments are correct, it can be very difficult to determine the accuracy of such varying payment titles. This is especially true when manufacturers report payments to physicians as aggregate totals throughout a given year.

CMS agreed that the nature of payment categories may be expanded or clarified in the future, but noted that a public forum—with input from all parties—would be necessary to change the system.

Another important point is that the deadline for recipient disputes is until the end of the reporting year for the particular payment. “Physicians, teaching hospitals, and principal investigators have until the end of the 2015 calendar year to initiate disputes of data submitted in 2015,” states CMS. While disputes made outside of the initial 45-day window will not immediately show up, they will be on the database by CMS’s next data refresh, which comes at least once a year, according to the agency.  Disputes about 2013 payment, however, are past the due date.

Some other important notes brought up during the call included the fact that there is currently no download functionality on the Open Payments review and dispute program. For hospitals that employ a large number of physicians with many pages of payments, this becomes a major inconvenience for those that simply want to download and print out their list of reported transfers of value. Also, hospitals will continue to be listed exactly as they appear in CMS’s teaching hospital list. Many had requested that manufacturers list the department of a given teaching hospital where payments were made, given the size of many institutions. CMS confirmed that the master hospital list is the guiding document.  

The PowerPoint has a good deal of important information for covered recipients, so it is worth looking at. CMS listed a number of tips for successful physician vetting (where CMS vets doctor profiles against “CMS-approved sources to confirm the registrant is a covered recipient”) that are important to point out:

• Make sure the name used for registration matches exactly with the name in the National Plan and Provider Enumeration System (NPPES). CMS notes: “If you changed your name in NPPES after Dec. 31, 2014, use the earlier version of your name that was in NPPES.”
• Enter NPI, if available. “Enter exactly as listed in NPPES for the current calendar year,” CMS states. “Do not enter NPI if it was obtained after Jan. 1, 2015.”
• Enter all active state license(s)
• “Provide as much information as possible – more information can speed vetting and ensure all records associated with the physician will be accurately matched to them,” CMS states.

View the PowerPoint for 2015 review and disputes here.