Sanction Checks & CMS Open Payments: Ensuring Compliance and Transparency in Healthcare A Guide for UK Healthcare Providers
Navigating the Regulatory Landscape
Why Sanction Checks Matter in Healthcare Compliance Protecting Programme Integrity
Mitigating Legal & Financial Risks
Sanction checks identify providers excluded from
CMS enforces strict denial, revocation, and re-
NHS, Medicare, Medicaid, or other federal
enrollment bar policies. Failure to perform diligent
programmes due to fraud, abuse, or legal violations,
sanction checks risks provider billing privileges,
safeguarding public funds and patient welfare.
significant legal penalties, and operational disruption.
Enhancing Accountability
CMS Open Payments: Promoting Transparency in Industry-Provider Relationships
Open Payments, mandated by the
The programme's core objective is to
Affordable Care Act Section 6002, is a
empower patients, regulators, and the
national disclosure programme. It
public with clear, transparent data on
requires pharmaceutical and medical
financial relationships that may
device manufacturers, and Group
influence healthcare decisions,
Purchasing Organisations (GPOs) to
fostering greater trust and ethical
report payments or transfers of value to
conduct within the industry.
physicians and teaching hospitals.
Key Components of CMS Open Payments Reporting
Reporting Entities
Covered Recipients
Data Reported
Pharmaceutical and medical device
Physicians, nurse practitioners,
Payments, ownership interests,
manufacturers, and GPOs are legally
physician assistants, and teaching
research funding, and indirect
required to submit data.
hospitals are subject to reporting.
transfers of value are all disclosed.
Where Compliance Crosses Over
Sanction Checks & Open Payments: Compliance Intersection
Excluded Providers
Providers sanctioned by CMS must be identified during enrollment and revalidation to avoid billing denials or revocations.
Undisclosed Relationships
Open Payments data can reveal financial relationships that may trigger sanction reviews, indicating potential conflicts of interest.
Maintaining Privileges
Both programmes require timely, accurate reporting and review to maintain Medicare billing privileges and ensure continued operation.
Open Payments Annual Cycle & Sanction Check Integration Data Collection Manufacturers and GPOs collect payment data from January 1 to December 31 each calendar year.
Sanction Checks Occur at enrollment, revalidation, and through ongoing monitoring to detect and mitigate risk affiliations.
Reporting Deadline Entities must submit their comprehensive reports by June 30 of the following year.
Recipient Review Covered recipients have a dedicated window (April 1 - May 15) to review and dispute any reported data.
This cyclical process ensures continuous oversight and accountability within the healthcare ecosystem.
The Stakes of Non-Compliance
Consequences of NonCompliance: Sanctions, Denials, and Public Disclosure
CMS can deny or revoke Medicare billing privileges for felony convictions, exclusions, or false reporting. Open Payments non-compliance risks significant financial penalties, legal action, and severe public reputational damage, which can severely impact patient trust and practice viability.
Providers must proactively monitor their sanction status and Open Payments disclosures to safeguard their practice and ensure continued operation in the highly regulated healthcare sector.
Practical Steps for Healthcare Providers 01
02
Regular Sanction Checks
Review Open Payments Data
Routinely check CMS and OIG exclusion databases to
Register and actively review your Open Payments data
ensure compliance and avoid issues.
annually, disputing any inaccuracies promptly.
03
04
Transparent Documentation
Staff Training
Maintain meticulous records of all financial relationships
Educate all staff on compliance requirements for both
and disclosures for audit readiness.
sanction checks and Open Payments reporting.
Resources & Support from CMS •
CMS Open Payments website: Comprehensive guides, FAQs, and dedicated help desk support for all your queries.
•
Medicare Provider Enrollment Compliance Conferences: Attend webinars and conferences for the latest regulatory updates and best practices.
•
Open Payments User Guide (2025): Access the detailed guide outlining reporting system functionalities and precise timelines for submission.
Conclusion: Integrating Sanction Checks with CMS Open Payments for Compliance Excellence
Combining rigorous sanction screening with transparent Open Payments reporting fundamentally strengthens healthcare integrity. Staying informed and proactive is paramount to protecting providers from enforcement actions and building invaluable patient trust. A steadfast commitment to compliance is not just a regulatory obligation; it is essential in today’s rapidly evolving regulatory landscape, ensuring ethical practice and sustainable growth.
Your compliance journey is a continuous commitment to excellence.
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