Many of you are aware that some monies (or other recompense) that a physician, teaching hospital, or certain categories of non-physician practitioner receives from pharmaceutical or device manufacturer is made available to the general U.S. public by Medicare through the “Open Payments” program. The purpose of this month’s column is aimed more to be sure you are aware of all the other information the CMS makes public about you or your practice.
Q: What is the purpose of all this information being available?
It’s mostly about transparency. Some things are still not released, but the trend is to give the public more information so that they can potentially make informed decisions based on real information and not just take a “guess.”
Q: You noted “Open Payments” has been there awhile. When is the next release of this information?
Open Payments (https://www.cms.gov/openpayments) has been part of CMS’ public data release for almost a decade. Usually the release to the public happens every year around June, so by the time you read this it may be out there already. As always, you have an opportunity to see your data and potentially contest it before release, and this year the deadline for doing so was May 15, 2021. Even if you didn’t check the information in advance, you should definitely go and look what the general public can see about you.
In 2021, CMS will collect information for eventual release on new types of providers such as Physician Assistants, Nurse Practitioners and a few others. These new providers don’t have their information released and published until 2022.
Q: Even though the deadline has passed for Open Payments review, how do I dispute incorrect information so it can be corrected for next year’s update?
It’s important to know that CMS clearly states they don’t mediate or get involved with disputes; they just relay and then publish what gets sent to them by manufacturers of covered products and some Group Purchasing Organizations. If you disagree with something, CMS notes you need to work directly with reporting entities (manufacturers, etc.). There are a couple of things to be aware of, though:
1) You can’t just ‘go see’ without registering in the Open Payments system, which you do by visiting the “Register as a Covered Recipient” website (https://www.cms.gov/OpenPayments/Program-Participants/Covered-Recipients/Registration). Once you are in, you can view your present and past data, and see instructions for making corrections.
2) Your account stays completely active for 60 days, if you exceed this, then you can unlock your account yourself in the CMS Portal.
3) If there’s no activity on your account in 180 days, it’s deactivated and requires you reach out to the Open Payments Help Desk by email or phone (OpenPayments@cms.hhs.gov; 855-326-8366; for a TTY line, call 1-844-649-2766).
Q: What information gets reported to Open Payments?
Some examples of the data that’s reported are fees or other considerations of value that you received such as travel/lodging, charitable contributions, royalties, consulting or speaker fees, entertainment, and even some research activities. Medicare, in a February 2021 presentation (https://www.cms.gov/files/document/open-payments-overview-and-enhancements.pdf), defines these payments/considerations as:
• Direct or indirect payments or other transfers of value made to covered recipients (physicians and teaching hospitals), and physician owners or investors
• A direct payment is a payment or other transfer of value made directly by reporting entities to a covered recipient (or a physician owner or investor)
• An indirect payment is a payment or other transfer of value made by a reporting entity to a covered recipient (or a physician owner or investor) through a third party, where the entity requires, instructs, directs, or otherwise causes the third party to provide the payment or transfer of value, in whole or in part, to a covered recipient (or a physician owner or investor)
• Certain ownership or investment interests held by physician owners or investors, or their immediate family membersCMS has a good webpage with resources: https://www.cms.gov/OpenPayments/Resources. Providers and Teaching institutions go to the “Covered Recipients” area.
Q: Is any of this information about the actual codes that I personally (or in my group) got paid for?
Yes, one of these public releases is officially known as the Medicare Provider Utilization and Payment Data (https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Physician-and-Other-Supplier). It is often colloquially referred to as the “Medicare data dump,” and has been in use since 2012. CMS notes this set of information “provides information on services and procedures provided to Medicare beneficiaries by physicians and other healthcare professionals. The Physician and Other Supplier PUF [Public Use File] contains information on utilization, payment (allowed amount and Medicare payment), and submitted charges organized by National Provider Identifier (NPI), Healthcare Common Procedure Coding System (HCPCS) code, and place of service. This PUF is based on information from CMS administrative claims data for Medicare beneficiaries enrolled in the fee-for-service program …” The data for each year’s release can be sorted and is available in two forms in addition to a couple of summary tables that have aggregated information by physician and by state and HCPCS code. The two forms of data are:
1. An online interactive dataset (you can sort and filter data directly without downloading)
2. Tab delimited file format (requires importing the downloaded information into database or statistical software; Statistical Analysis System read-in language is included in the download ZIP package)
CMS also notes that this data has some limitations: The “data may not be representative of a physician’s entire practice as it only includes information on Medicare fee-for-service beneficiaries. In addition, the data are not intended to indicate the quality of care provided and are not risk-adjusted to account for differences in underlying severity of disease of patient populations …”
Q: I heard that there is also a data set that I could use to compare my practice to others. What’s that?
This information has been available since 2010, and is known as the Physician/Supplier Procedure Summary (https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Physician-Supplier-Procedure-Summary). This is basically utilization information about specific codes paid over a recent year by Medicare (not Medicare Advantage or private payers). Importantly, this data cannot be sorted on a specific provider, instead it’s more general. It can be sorted by specialty, however, so you could use this information to get general benchmarks about the average eye-care practice (optometry and ophthalmology) for codes billed. Non-billed services are not available, of course, as no claims were ever submitted for them. CMS notes the file “… is organized by carrier, pricing locality, Healthcare Common Procedure Coding System (HCPCS) code, HCPCS modifier, provider specialty, type of service, and place of service …”
Importantly, the 2019 data is different due to some new filters applied by CMS which restricted the size of the data available, so it may be less useful than prior years. It is usually available in late summer or early fall.
Q: What do I need to know about the Quality Payment Program (QPP) data being released this year for the first time?
A small amount of this information has been available for the past two years, but in 2021 some additional information about the 2019 QPP results of a practice/provider will be released over the summer. There are two parts of the information, and they are released in different searchable databases: 1) Medicare Care Compare, and 2) Provider Data Catalog.
CMS notes that Medicare Care Compare is designed to “help patients and their caregivers select doctors and clinicians.” It includes such things as practice information (physical location, specialty, education/residency and board certification), whether the practice participates in an Alternative Payment Model (APM), some MIPS Star ratings and attestations, as well as any Accountable Care Organization performance.
According to a CMS poster presentation (https://www.cms.gov/files/document/2021-cms-quality-conference-poster.pdf) in early March 2021, the Provider Data Catalog is for more research-focused audiences. The Catalog is in tabular format, and will have practice information as well as “Performance information … [on] … MIPS Final Scores and Performance Category scores; clinician utilization data; and aggregate data.” Importantly, the scores from the Cost measures don’t meet national reporting standards according to CMS and won’t be released this year. However, your total Composite score will be released even though the specific data surrounding the Cost measures isn’t.
Mr. Larson is a senior consultant at the Corcoran Consulting Group and is based in Tucson, Arizona. He can be reached at firstname.lastname@example.org.