Open Payments is a national program that is focused on promoting transparency by making data on the financial relationships between the healthcare industry (applicable manufacturers and group purchasing organizations or GPOs) and healthcare providers (physicians and teaching hospitals) publicly available. With such extensive data published every year, enforcement authorities have literally acquired a gateway to data heaven as it allows them to perform investigations that may not have been possible before.

There are many different ways in which enforcement authorities are currently using and plan on using transparency data in times to come. If anything, the utilization of this data has helped authorities uncover a number of cases pertaining to healthcare fraud.

The Different Ways in Which Cases Are Evaluated and Developed

The authorities regularly use data mining for the evaluation and development of cases. This particularly holds true for matters that are brought to their attention through qui tam realtors. In general, the government encourages federal investigators to use the data for the proactive identification of potential fraud and abuse. With time, the use of the Open Payments data will continue to increase as the offices become more skilled at working with it.

Speaking in general, data analytics isn’t an entirely new concept within the healthcare industry. However, with data analytics tools becoming all the more accessible, law enforcement agencies are taking more and more interest in using it for the detection of healthcare fraud. Government investigators have additionally been rather vocal in informing the healthcare industry that they plan on continuing the usage of this powerful tool for the evaluation and development of cases pertaining to healthcare fraud.

According to a statement released in a work plan by the Office of Inspector General, U.S. Department of Health and Human Services, law enforcement determines the number and nature of financial interests reported to CMS under the Open Payment Programs. Further, they determine the amount that was paid by Medicare for drugs and medical supplies ordered by physicians who held financial relationships with manufacturers and GPOs reported to CMS. Authorities then determine the extent to which data in the open payments system is missing or inaccurate and whether the data required for physician and teaching hospital payments is valid.

Using Open Payments Data Together with Other “Big Data”

Government reliance on data analytics continues to increase, and they now have Open Payments and Medicare Provider Utilization and Payment Data databases available to them as well. These databases are used by the authorities to:

• Evaluate FMV

• Identify or confirm relationships

• Look for outliers in terms of number, value and types of payments

What Can be Expected in the Years Ahead?

In times to come, CMS and law enforcement agencies will likely begin conducting Open Payment audits and pursue civil monetary penalties. Scrutiny of financial relationships with HCPs will be on the rise, and federal enforcement authorities will particularly focus on and target potential kickbacks. It is also possible that federal and state enforcement authorities will cross-reference their respective data sets to pressure-test compliance with applicable laws and requirements.

Moving forward, manufacturers should expect more informal inquiries and requests for comment, etc., from media outlets and state authorities, among others. With time, the industry may also see state legislatures undertaking efforts to place further restrictions on its interactions with HCPs.