Physician Payments Sunshine Act: Manufacturers See Their Submitted Open Payments Data Disappear, Is NPPES System To Blame?

This week, scores of executives from pharmaceutical and device companies gathered in Washington, DC for CBI’s Eighth Annual Transparency and Aggregate Spend Forum to gain new insights into Sunshine Act compliance. On Monday, most companies were talking about rumors of one-third of the Open Payments data being withheld from the website until next year. Yesterday, we found out that the keynote speakers, the Centers for Medicare and Medicaid (CMS) were not able to attend the conference. Today? Who knows.

While we first heard of the withheld data in regards to a ProPublica story, many attendees logged in to Open Payments yesterday with horror during the conference to find a portion of their submitted payments erased from the system—some as much as one-half of the data.

On August 15, CMS released a statement regarding their decision to take the Dispute Resolution process offline.

“A full investigation into a physician complaint found that manufacturers and group purchasing organizations (GPOs) submitted intermingled data, such as the wrong state license number or national provider identifier (NPI), for physicians with the same last and first names. This erroneously linked physician data in the Open Payments system.”

There are some issues that jump out from this analysis.

–First, the Office of the Inspector General (OIG) for the US Department of Health and Human Services (HHS) last year found that “[d]ata in at least one field were inaccurate in 48% of inspected records in the NPPES.”

–Second, the problem with linking NPI to license numbers is that the license numbers in the NPI database are self-entered by the registering physician. This means that many of the state license numbers in that database are wrong.  

–Third, many doctors don’t have NPI numbers, including most dentists. Having an NPI number is not a requirement of being a doctor–having a state medical license is. Many doctors are also now employed by hospitals, and the hospital bills directly under their NPI number, or in group practices that often bill to one NPI number.

–Fourth. However, the most alarming problem with the NPPES database at this point appears to be a discrepancy between how NPPES lists medical license numbers. We looked up the common name John Smith in New Jersey’s License Number database.

We found that doctors in NJ had license numbers that started with “25” and ended with “00.” However, in the NPPES database, the system apparently cut-off these beginning and ending identifiers, including in some instances the “0” at the beginning of the number.

While this may explain some of the withholdings, at least one company noted that all of their clinical research data had disappeared; another had their physician demographic information remain the same, but certain payments were deleted. Others saw no rhyme or reason to the deleted data.

What we did hear from manufacturers, and corroborated by physician presenters and audience members, was that plenty of accurate spend information that was in the system last week is gone today.

An unfortunate aspect of the timing of this is that physician engagement in the dispute resolution phase was supposed to be at an all-time high at this point. Now, with the challenging registration system, off-line period, and incomplete data set, there has been less of a push for companies to use this as a data-integrity resource, a and a disincentive for physicians to check their payments.  

Today, CMS addressed why many records have been deleted from Open Payments. As we wrote, many of the problems are tied to the reliance on the NPPES database.

***UPDATE AT 12:30 p.m.***

“Records submitted to Open Payments are considered invalid if:

1. The NPI, state license information, and first and last names given for the physician in the record do not all exactly match against CMS data sources.*

2. The physician in the record has an NPI according to CMS data sources*, but the NPI is not included in the record, in accordance with 42 C.F.R. §403.904(c)(3)(ii).

3. The physician in the record validly has no NPI and the state license information and first name and last name given in the record do not all exactly match against CMS data matching sources.**

4. The physician in a general or research payment record submitted by an applicable GPO does not also have an ownership interest record submitted for that same GPO, in accordance with 42 C.F.R. §403.906(b)(6).

5. The legal business name and TIN of the teaching hospital in a general or research payment record do not exactly match to the corresponding information in the CMS list of approved teaching hospitals.

6. A research payment record in which any physician covered recipient principal investigators’ NPI, state license information, and first and last names given in the records do not exactly match against the CMS data sources*, in accordance with 42 C.F.R. §403.904(f)(1)(v).

* National Plan and Provider Enumeration System (NPPES) and the Provider Enrollment, Chain and Ownership System (PECOS)”

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