Medicomp Inc

Open Payments
Training

Creating Public Transparency of IndustryPhysician Financial Relationships

Open Payments is a national disclosure program that
promotes transparency by publishing the financial
relationships between the medical industry and healthcare
providers (physicians and hospitals) on a publicly
accessible website developed by CMS. This public website
(to be available no later than September 30, 2014) will be
organized and designed to increase access to and
knowledge about these relationships and to provide
information to enable consumers to make informed
decisions.

What that means for Medicomp

Medicomp will need to report to CMS on an
annual basis any payments or transfers of
value that have been made to a physician.

How does this affect the Sales Team

When providing any food or beverage to a
site it must be reported.

Steps to reporting
1. When providing lunch have ALL
participants sign the sign in sheet
2. Fill out a Google form for each physician
who participated
3. Submit your expense reports with the
normal procedure to Susan

Sign in sheet
The lunch sign in sheet is located on the
sales site under forms & templates
This should be signed by all who participate
(except a Medicomp representative)
Do not prefill the sign in sheet

Sign in sheet
Company Name
(required)
Adv Cardiology
Printed Name required

Primary Business
Address (required)

Business Purpose

08/15/2015

123 Heart Lane

Melbourne FL 32904

Title/Position

Jane Doe

receptionist

Marcus Welby, MD

physician

Date (required)

NPI & State License # required

Signature required

Jane Doe
1234567895 ME1234

Marcus Welby

MD
John Doe

john Doe

Information needed for completing the

Google form
Physician name
Address
NPI
State license number
Taxonomy
Total per person payment
Date of payment

How to obtain physician information

https://npiregistry.cms.hhs.gov
Click on individual provider
Search by physician NPI
This will give you the State License number
and taxonomy to be reported on the Google
form

How to get the total per person payment to

be reported
To obtain the total payment to be reported
you will take the total for the lunch and
divide it by the number of participants.
Total for Food
& Beverage
BILLYJOS SANDWICH SHOP
Sandwich platter $52.00
5 bottled water $ 6.00
Cookie platter
$ 8.00
subtotal: $63.00
tax: $ 3.30
Total: $66.30

Tip
10.70

77

Total # of
Participants

Per
person
total

3 = $25.66

Completing the Google form

The form will be shared with you. You must save the link as one of your
favorites or on your desktop to have easy access to it.
A form will need to be completed when a physician participates in the
food/beverage.
The form must be completely filled out.
The date of payment is the day you provided the food/beverage
Form of payment or transfer will always be number 2 In-kind items or
services
Nature of payment should always be number 6 Food and beverage
Number of payments should always be 1
You should sign the Google form with your full name or first initial full
last name. Just initials are not acceptable.

Open Payments Google Form

Open Payments Tracking Form (Sunshine Act )
OPEN PAYMENTS creates greater transparency around the financial relationships of manufacturers, physicians, and
teaching hospitals. OPEN PAYMENTS requires that the following information is reported annually to CMS:
Applicable manufacturers of covered drugs, devices, biologicals, and medical supplies to report payments or other
transfers of value they make to physicians and teaching hospitals to CMS.

Your username (jpaiva@medicompinc.com) will be recorded when you submit this form. Not jpaiva? Sign out

* Required

1. Physician First Name*

Name of the physician receiving payment or transfer of value
Marcus
2. Physician First Name*
Name of the physician receiving payment or transfer of value
Welby
3. Physician Suffix
Jr, Sr, II, III
4. Physician Primary Business Street Address Line 1 *
Including building number, street name, street identifier
123 Heart Lane

Open Payments Google Form

* Required

5. Physician Primary Business Street Address Line 2*

suite number, apartment number, po box number
Suite 101
6. Physician Primary Business City*
Melbourne
7. Physician Primary Business State *
limited to two characters
FL
8. Physician Primary Business Zip Code*
exactly 5 numeric digits
32904
9. Physicians Primary Type*
Type of medicine practiced

1. Medical Doctor (MD)

2. Doctor of Osteopathy (DO)
3. Doctor of Dentistry (DDS)
4. Doctor of Podiatric Medicine (DPM)
5. Doctor of Optometry (OD)
6. Chiropractor (DCP)

Open Payments Google Form

* Required

10. Physician NPI number*

1234567891
11. Physician Primary Taxonomy*
207RC0000X
12. Physician State and License Number*
should be entered as state abbreviation with hyphen then full state license# - SC-21543
FL-ME1234
13. Total of Payment per Person*
only the per person total should be reported
$25.66
14. Number of Payments included in total*
answer should always be 1
1
15. Form of Payment or Transfer*
please default answer number 2
o
o
o
o

1. Cash or Cash equivalent

2. In-kind items and services
3. Stock, stock option, or any other ownership interest
4. Dividend, profit, or other return on investment

Open Payments Google Form

* Required

16. Nature of Payment or Transfer of Value*

Please default answer to number 6
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o

1. Consulting fee
2. Compensation for services other than consulting, including serving as a faculty or as a
speaker at a venue other then a continuing education program
3. Honoraria
4. Gift
5. Entertainment
6. Food and Beverage
7. Travel
8. Education
9. Charitable contribution
10. Royalty or license
11. Current or prospective ownership or investment interest
12. Compensation for serving as faculty or as a speaker at an non-accredited and noncertified continuing education program
13. Compensation for serving as faculty or as a speaker at an accredited and certified
continuing education program
14. Grant
15. Space rental or facility fee (teaching hospital only)

Open Payments Google Form

Additional Notes

In compliance with the Federal Physician Payments Sunshine Act I attest that
the information entered into this form is accurate and true. I also understand
that by not supplying accurate and true information will result in disciplinary
actions.*
Electronically signed by:
Jill Paiva
Send me a copy of my responses

submit

Submitting your documentation

Copies of receipts and sign in sheets should
be submitted with your expense reports to
Susan as you would normally do
Please keep a copy for yourself in the event I
need additional information when reconciling
Your expense report will not move on for
further payment approval until you have
completed the Google form correctly

Helpful Hints
If there is not physician that participates you do
not have to fill out a form. You can write on the
sign in sheet NO MD.
You are not allowed to drop snacks, food or
beverages off and not stay
We need the physicians signature on the sign in
sheet as documentation that they did participate
A FAQ will be shared with you and is available on
the Google drive

Questions
Please contact:
Jill Paiva, CPCO
321-821-2032
jpaiva@medicompinc.com