An End To CMS Open Payments Disputes, But What Next?

By Ben Carmel

cmsAs the CMS Open Payments Review and Dispute window for 2013 data comes into its final stretch, the industry is left looking for answers and scratching our collective heads for next steps. Sure everyone knows that data must be resubmitted based on any disputes that HCP/Os logged, but what about all of the missing data?

As initially reported in a variety of outlets including Policy & Med, CMS removed a significant portion of spend that have been previously attested and in many cases reviewed by covered recipients. Polaris logged into our client specific data submissions in the portal and have found in many cases that the data removed exceeds the 33% originally outlined by CMS.

After discussions with CMS around the missing data, Polaris is advising clients not to worry about resubmission of the missing data at this point in time. There is still too much unknown to warrant the effort. What does need to be evaluated is how to resubmit disputes. Depending on volume and given that “missing data” is unknown currently to manufacturers, we are recommending a manual approach to correct through the portal, as opposed to a full data file resubmission. Changes can still be made to a new version of your full data file, so everything is in sync.

Polaris independently verified data from across our clients and can confirm that, if nothing else, there are issues with state license data in the CMS NPPES database.

The big reason for the deletions had to do with a change in the match rules that occurred in the CMS Open Payments system during the portal shutdown. According to CMS, “During the maintenance period, CMS verified that the physician and teaching hospital identifiers reported by applicable manufacturers or applicable group purchasing organizations (GPOs) were accurate and matched data in CMS data sources. This matching serves to ensure that payment records were attributed to the correct physician or teaching hospital. As a result, some current payment records within the system are now considered invalid and will need to be corrected.”

Polaris independently verified data from across our clients and can confirm that, if nothing else, there are issues with state license data in the CMS NPPES database.

For example, state specific nuances in licensing were not picked up on by CMS. In a Maryland example, the state stores the license number for Abdul Soudan as D63349.

MDState-Soudan

NPPES does not drop the leading zeroes the way the state does, and has Abdul Soudan with a license of D0063349.

CMS Open Payments

It is our assumption that previously CMS was focused on NPI number matches, but with the David E Mann issues, it has tightened up match logic to focus more on state license numbers. The downside is that with invalid or old data in NPPES, many records will not match properly.

So where do we go from here?

Perhaps for now, we wait.  CMS has not yet determined a process or set dates for resubmission of invalidated data, only that we know it will not take place until Q4 2014.

According to CMS “These invalid payment records have been removed from the current review and dispute process and will be returned to the applicable manufacturer or applicable GPO who submitted them so they can be corrected and re-submitted. CMS will contact affected applicable manufacturers and applicable GPOs, using the contact information associated with their Open Payments registration profile, to provide additional instructions on how to correct and re-submit their records after September 30, 2014.”