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An Introduction to the Physician Payment Sunshine Act

You can refer to The Physician Payment Sunshine Act as the “Sunshine Act” in short. It was enacted in the United States in 2010 as part of the Patient Protection and Affordable Care Act. It aimed to improve the transparency of payments.

The Sunshine Act is linked to the public’s demand for more openness in the medical device and pharmaceutical sectors. Industry and some healthcare providers must record specific financial transactions. They must make them public every year under the Sunshine Act.

These reporting entities report this information using the Open Payments initiative. Then, the Centers for Medicare & Medicaid Services (CMS) publishes the info.

Let’s now delve a little further into the implications of the Sunshine Act. We’ll also touch upon dispute resolution and management concerning healthcare providers.

A History of Concerns

It’s nothing new to see concerns about healthcare providers and industry connections. Furthermore, there’s also been a concern of industry influencing prescription trends.

JAMA established rules on industry gifts to physicians in 1991. The New England Journal of Medicine published an essay in the same year. It was by then-US Food and Drug Administration Commissioner David A. Kessler, MD. He questioned the impact of industry on sponsored continuing medical education programs.

More Recent Concerns

Several publications before the Sunshine Act expressed misgivings about deceptive drug advertising. Some looked at government investigations into the omission of data. This was from peer-reviewed publications reporting the results of industry-sponsored clinical trials.

Plus, there were some industry publications with recommendations to close the credibility gap.

Over time, we saw several US states pass legislation. It required public disclosure of different financial ties between industry and healthcare providers.

All this has culminated in the US Federal Government’s Sunshine Act. In addition, countries in Asia, Canada, and Europe seemed to have followed comparable advice and laws since the Sunshine Act was passed.

Open Payments

Open Payments is a nationwide disclosure initiative. It aims to make the healthcare system more open with payment transparency. It falls in line with the Sunshine Act’s recommendations and requirements.

Open Payment is a public database of payments made to entities such as physicians. The payments tend to be from pharmaceutical and medical device firms.

Participants of Open Payments

The Open Payments initiative has two categories of participants. Pharmaceutical companies, and medical device firms are examples of reporting entities. The following people are covered receivers:

  • All physicians who aren’t employed by the reporting body (except medical residents)
  • Some non-physicians
  • Teaching hospitals receiving Medicare funds for direct GME, IPPS, or IME programs

Both reporting entities and covered receivers have specific roles and responsibilities. Reporting entities must submit their reports every year that they make to covered receivers. If you are a covered receiver, you have the right to dispute and review the information that reporting entities submit about you.

Dispute Management for Covered Recipients

Since the beginning of the Open Payments initiative, reporting entities have reported billions of dollars of payments. And these payments stack up to over one million physicians, as well as other receivers.

As a potential covered receiver, you might not think that reporting entities will disclose data about you in a particular year. But, every year, you should double-check your data.

Reporting organizations may submit information from past years. Once they submit any data, you will have a pre-publication review and dispute timeframe. This is your chance to evaluate and challenge the data before the CMS website publishes your information.

To review and dispute any potential information about you, you need a DisputeID. This is so you can log into the CMS website in a secure manner. After this, you would move on to dispute resolution to ensure that you get any false reports corrected.

Reviewing and Disputing Your Information

The CMS allows covered recipients a 45-day review and dispute timeframe each year. This is so you can verify your data is correct before they publish it.

The review and dispute procedure is optional. Yet, the CMS encourages covered recipients to review and challenge their data

When Can You Review Your Data?

The pre-publication review and dispute period runs from April 1st to May 15th. Before the CMS releases your data, you should review it and challenge any errors at this time of year.

May 15th to 30th is the timeframe to carry out any Data Correction.

If you filed a dispute between April 1st and May 15th, reporting entities have the opportunity to amend data before the CMS makes it public. Then, the CMS will publish corrections to disputes received before December 31st and after May 15th.

How Do You Review Your Data?

First, register with the CMS Identity Management System (IDM). Then you can use the Open Payments System and check your data. Visit the Resources for Covered Recipients website. There you will find more information on registration and review, and dispute activities.

You can choose someone to carry out system-related tasks on your behalf. For example, you can evaluate and dispute your data. You may learn more about designating an authorized representative on the CMS website.

The Physician Payment Sunshine Act

We’ve now explained a little about the Physician Payment Sunshine Act. But, more importantly, we’ve talked about dispute management regarding your data being published.

Healthcare professionals need to make their data accurate on the Open Payments System. If not, it could be damaging to their reputation. Healthcare professionals can hire professionals to make sure everything is correct.

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