Overview of Data Bank Reporting Requirements

Overview of Data Bank Overview of Data Bank Reporting RequirementsReporting Requirements

Elizabeth Rezaizadeh, MPH U.S. Department of Health and Human ServicesHealth Resources and Services Administration

Bureau of Health ProfessionsDivision of Practitioner Data Banks

Utah Association of Medical Staff Services (UAMSS)

One Day SeminarAugust 12, 2011

1

Presentation OverviewPresentation Overview

• Bureau of Health Professions (BHPr) Mission

• National Practitioner Data Bank Laws, Regulations, Reporting and Querying

• Healthcare Integrity and Protection Data Bank Laws, Regulations, Reporting and Querying

• Discussion Scenarios

• Entity Registration

2

HRSA’s Bureau of HRSA’s Bureau of Health ProfessionsHealth Professions

3

Bureau of Health ProfessionsBureau of Health Professions

2010 Reorganization

Division of Public Health and

InterdisciplinaryEducation

Division of Medicine

and Dentistry

Division of Nursing

Division of Practitioner Data

Banks

Division of StudentLoans and

Scholarships

Division of Workforce andPerformanceManagement

National Center for

WorkforceAnalysis

Area Health EducationCenter Branch

Diversity Branch

Geriatrics andAllied Health Branch

Oral Health TrainingBranch

Primary CareMedical Education

Branch

Community-BasedTraining Branch

Advanced NursingEducation Branch

Community-BasedNursing Branch

Nursing Diversity and

Development BranchCompliance andDisputes Branch

Operations andAdministration Branch

Loan RepaymentPrograms Branch

HEAL Branch

Campus-BasedBranch

State WorkforceDevelopment Branch

Performance Managementand Program Evaluation

Branch

Office of Administrative Management Services

Office of Shortage Designation

Office of Policy Coordination

Office of the Associate Administrator

Office of SpecialInitiatives

Policy andResearch Branch

Public HealthBranch

Children’s HospitalTraining Branch 4

BHPr MissionBHPr Mission

Increase the population’s access to health care

by providing national leadership in the

development, distribution and retention of a

diverse, culturally competent health workforce

that can adapt to the population’s changing

health care needs and provide the highest

quality of care for all. 5

Division of Practitioner Division of Practitioner Data BanksData Banks

The Division of Practitioner Data Banks

(DPDB), part of the Bureau of Health

Professions, is committed to the

development and operation of cost-

effective and efficient systems that offer

accurate, reliable, and timely information

on practitioners, providers, and suppliers

to credentialing, privileging and

government authorities. 6

The National The National Practitioner Data Practitioner Data

BankBank

7

National Practitioner Data BankNational Practitioner Data Bank(NPDB) (NPDB)

Laws and RegulationsLaws and Regulations

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• Established through Title IV of PublicLaw 99-660, the Health Care Quality Improvement Act of 1986 (HCQIA), as amended

• Part A – Promotion of Professional Review Activities– Established immunity provisions– Developed through case law, not Federal

regulations

• Part B – Reporting of Information– Established the NPDB

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NPDBNPDB

10

The law’s intent is to restrict the

ability of incompetent physicians,

dentists, and other health care

practitioners to move from State to

State without disclosure of previous

medical malpractice payment and

adverse action history.

NPDBNPDB

Section 1921Section 1921

• Public Law 100-93, Section 5 of the Medicare and Medicaid Patient and Program Protection Act of 1987 (Section 1921 of the Social Security Act)

• Section 1921 amended by the Omnibus Budget Reconciliation Act of 1990, Public Law 101-508

• Final regulations codified at 45 CFR Part 60

• Final Rule for Section 1921 published in the Federal Register January 28, 2010

• Implementation of Section 1921 effective March 1, 2010

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12

Its intent is to protect beneficiaries

participating in the Social Security

Act’s health care programs from

unfit health care practitioners and

improve the anti-fraud provisions of

these programs.

Section 1921Section 1921

NPDB Expansion: Section NPDB Expansion: Section 19211921

Section 1921 of the Social Security Act– Expands the information collected and

disclosed by the NPDB

– Authorizes new types of organizations to query and receive Section 1921 information

– Requires new organizations to submit reports concerning practitioners and providers to the NPDB, such as state licensure boards for practitioners other than dentists or physicians, as well as for health care organizations

13

NPDB ReportingNPDB Reporting

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Overview of NPDB Overview of NPDB

• The NPDB does not collect full records of reported incidents or actions and is not designed to be the sole source of information about a practitioner.

• If an NPDB report indicates that a settlement was made by or on behalf of a practitioner, it should not be assumed that negligence was involved.

• Credentialing and privileging should be an objective and circumspect process using all available resources to make an informed decision about a practitioner. 15

NPDB: Who Must Report?NPDB: Who Must Report?

• Malpractice insurers and self-insured organizations

• State licensing boards for all health care practitioners and entities

• Hospitals, managed care organizations, other health care entities with formal professional review process Health care entity provides health care services and follows a formal professional review process to further quality health care.

16

NPDB: Who Must Report? NPDB: Who Must Report? (Continued)(Continued)

• Professional societies and memberships with formal professional review process

• Peer review organizations – Excludes Quality Improvement Organizations

• Private accreditation organizations – e.g., Joint Commission, URAC (formerly known

as the Utilization Review Accreditation Commission), & National Council for Quality Assurance (NCQA)

• Drug Enforcement Administration and HHS Office of Inspector General Based on Memorandum of Understanding with HHS

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NPDB: Overview of What is NPDB: Overview of What is ReportedReported

1. Medical malpractice payments

2. Adverse clinical privilege actions taken in the course of professional review activity

3. State licensure actions taken against all health care practitioners and entities

4. Negative actions or findings by peer review organizations and private accreditation organizations

5. Medicare/Medicaid exclusions

6. Adverse registration actions to prescribe controlled medicine taken against health care practitioners

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1. Medical Malpractice Payments

• Each person, entity, or insurer that makes a payment under an insurance policy, self-insurance, or otherwise, for the benefit of a physician, dentist, or other health care practitioner in settlement or judgment against a practitioner for medical malpractice must report this payment to the NPDB.

• Payments made by federal agencies are also reportable.

• Employers who insure their employees must report medical malpractice payments.

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NPDB: What is Reported? NPDB: What is Reported?

What Is Reportable?

• Reportable medical malpractice payments are:– The result of a

written complaint or claim demanding payment

– Based on provision or failure to provide health care services

– Based on tort law20

What Is Non-Reportable?

• Payments made in situations where there was no written claim or complaint

• Payments made to satisfy claims against health care entities that do not identify individual practitioners (Corporate Shield)

• Individuals who make a malpractice payment from their own personal funds


1.Medical Malpractice Payments

What is Reportable?

• All professional review actions taken which:– Concern physicians or dentists

– Are based on professional competence or conduct that adversely affects, or could adversely affect, the health or welfare of a patient

– Adversely affect clinical privileges or professional society membership for a period longer than 30 days

– Voluntary surrender or restriction of clinical privileges or professional society membership while under, or to avoid, investigation

– Summary or emergency suspensions resulting from a professional review action

21 Other practitioners MAY be reported


2. Adverse Actions Overview


What is Non-Reportable?

• Adverse Actions taken without a formal professional review

• Actions that do not last longer than 30 days

• Actions that do not affect or could adversely affect the health or welfare of a patient

2. Adverse Actions Overview

22

Section 1921 expands the current NPDB adverse licensure action reporting requirements in two ways:

• State licensing authorities must report adverse actions taken against all health care practitioners, not just physicians and dentists, as well as those actions taken against health care entities.

• State licensing authorities must report all adverse licensure actions (not just those based on professional competence and conduct). 23

3. State Licensure Actions


What is Reportable?

• License revocations, restrictions, suspensions, surrenders, censures, reprimands, and probations

• Any dismissal or closure of formal proceedings by reason of the practitioner or entity surrendering the license or leaving the State or jurisdiction

• Voluntary surrenders or withdrawal of an application for license renewal or a denial of an application for license renewal, and licensure non-renewals (excluding those due to nonpayment of licensure renewal fees, retirement, or change to inactive status)

• Summary or emergency suspensions

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25

What is Reportable? (Continued)

• Any negative action or finding that under the State’s law is publicly available information and is rendered by a licensing or certification authority, including, but not limited to, limitations on the scope of practice, liquidations, injunctions and forfeitures (This definition excludes administrative fines or citations, and corrective action plans, unless they are: connected to the delivery of health care services, or taken in conjunction with other licensure or certification actions such as revocation, suspension, censure, reprimand, probation, or surrender.)

• Revisions to previously reported adverse licensure actions, such as reinstatement of a license




• Monitoring, continuing education, completion of other obligations (unless it constitutes a restriction, a reprimand, etc.)

• Stayed actions

• Voluntary relinquishment of license for personal reasons (e.g., retirement or change to inactive status)

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What is Reportable?

• A negative action or finding to sanction a health care practitioner

• Any final determination of denial or termination of an accreditation status that indicates a risk to the safety of a patient(s) or quality of health care services. These are taken against health care entities only.

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4. Peer Review & Private Accreditation Organizations



• Any action that is not a result of a formal proceeding

*Must be the result of formal proceedings with due process

What is Reportable?

The NPDB contains reportsconcerning

Medicare/Medicaidexclusions against health

carepractitioners.

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5. Medicare/Medicaid Exclusions


OIG and HHS reports which do

not concern actions taken against

health care practitioners who

participate in Medicare/Medicaid

programs.


What is Reportable?

The Drug EnforcementAdministration (DEA) reportsadverse registration actions onall health care practitioners

whodispense controlled

substances.

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6. Adverse Registration Actions


Registration Reports onpractitioners who do

not havea Federally assigned

DEAidentification number todispense medication.


NPDB Reports from September 1, 1990 through December 31, 2010

48.3%44.2%

5.0%

2.3% 0.1%

0.1%

NPDB Reports by Type (N = 803,843)

State Licensure: 48.3%, N=388,489

Medical Malpractice Payment: 44.2%, N= 355,102Exclusion/Debarment: 5%, N=40,227

Title IV Clinical Privileges: 2.3%, N=18,491

Professional Society: 0.1%, N=911

DEA/Federal Licensure: 0.1%, N=623

Total Number of Reports in Total Number of Reports in NPDB NPDB

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26.0%

25.6%19.2%

14.2%

15.0%

Five Most Frequently Cited Adverse Actions Against Individual Practitioners

Probation of License

Reprimand or Censure

Suspension of License

License Revoction

Exclusion from Medicare, Medicaid, Other Fed. Programs

Top 5 NPDB AARs by Type Top 5 NPDB AARs by Type

NPDB Reports from September 1, 1990 through December 31, 2010 31

NPDB Reports By NPDB Reports By Practitioner Practitioner

Physicians 376,303 Professional Nurses 131,421 Para-Professional Nurses 124,764 Dentist 66,819 Pharmacists and Assistants 28,017 Chiropractors 15,725 Podiatrists/Assistants 9,993 Counselers/Marriage/Family Therapist 7,270 Physical Therapists and Assistants 5,386 Social Workers 4,894 Psychologists/Assistants/Associates 4,836 Physician Assistants 4,244 Emergency Medical Technicians (EMT) 4,137 Respiratory Therapists/Technologist 3,987 Other Rehab/Restorative Service Practitioners 3,035 Other Technologists/Techs 2,513 Dental Assistants/Hygienists 2,424

*Reporting entity did not identify Occ/Field of State Licensure Code

Data from September 1, 1990 through December 31, 2010

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NPDB Reports By Practitioner NPDB Reports By Practitioner (Continued)(Continued)

Optometrists 2,386 Occupational Therapists/Assistants 1,355 Speech/Language Pathologists/Audiologists 1,011 Assistant Devices Service Practitioners 869 Complimentary Medicine Practitioners 671 Organization 553 Other Health Care Practitioners 496 Unspecified or Unknown Individual* 407 Dieticians/Nutritionists 143 Medical Assistants 68 Health Care Facility Administrators 65 Other Health Care Occupation 46 Non-Health Care Occupation 3 Researcher, Clinical 2 Total 803,843

Data from September 1, 1990 through December 31, 2010

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51.6%

0.4%

9.2%

0.0%2.8%

0.1%0.9%

17.5%

0.7% 16.6%

NPDB Reports on Physicians, Nurses & Pharmacists

Physicians (MD, DO)

Physician Interns (MD, DO)

Dentists

Dental Assistants

Pharmacists

Pharmacist Interns and Assistants

Pharmacist Specialists and Technicians

Regsitered Nurses (RN)

Advanced Practice Nurses

Vocational Nurses, Nursing Assistants

NPDB Reports from September 1, 1990 through December 31, 2010

Top 10 Practitioner NPDB Reports Top 10 Practitioner NPDB Reports by Typeby Type

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Querying the NPDBQuerying the NPDB

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Querying the NPDBQuerying the NPDB

Hospitals Must Query by Law:

– When physicians, dentists, and other health care practitioners apply for staff appointments (courtesy or otherwise) or for clinical privileges; and

– Every 2 years on all physicians, dentists, and other health care practitioners who hold clinical privileges at the hospital.

36

Querying the NPDB Querying the NPDB (Continued)(Continued)

Hospitals May Query:

– At any other time with respect to professional review activities.

37


The Following May Query the NPDB:

1. State licensing boards

2. Other health care entities with a formal peer review process

3. Professional societies with a formal peer review process

4. Health Care Providers (self-query only)

5. Researchers (non-identifying data only)38

The Following May Query the NPDB

under Section 1921:

1. Agencies administering Federal Health Care Programs and their contractors

2. State agencies administering State Health care programs

3. State Agencies that license health care entities

4. Quality Improvement Organizations (QIOs)

39


The Following May Query the NPDB

under Section 1921:

5. Medicaid Fraud Control Units

6. U.S. Attorney General and other law enforcement

7. U.S. Comptroller General

40


Access to Section 1921 Data ONLY

– Entities that are currently allowed to query the NPDB have access to all Section 1921 reports e.g., hospitals, health care entities, State boards

– Entities given access to the NPDB through Section 1921 are allowed to query ONLY Section 1921 information

– Practitioners and entities can self-query only

– Researchers can use non-identifying data only

These entities also have access to Medicare/Medicaid exclusions

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1.4%

36.4%

51.9%

0.3%0.9%

8.8%

0.2%

NPDB Queries (N=59,429,343)

Self Queries - 858,278

Hospitals - 21,655,824

Health Plans - 30,859,762

Govt Programs - 175,763

State Licensing Agencies - 511,444

Other Service Providers - 5,222,738

Professional Societies - 145,534

NPDB Queries NPDB Queries

42NPDB Queries from September 1, 1990 through December 31, 2010

NPDB: Summary of Other NPDB: Summary of Other ProvisionsProvisions

• Timeframe for reporting is within 30 days of the date of the adverse action or the date a medical malpractice payment was made.

• Medical malpractice payers and health care entities must send a copy of the NPDB report to the appropriate State licensing board.

43

NPDB: Summary of Other NPDB: Summary of Other Provisions Provisions (Continued)(Continued)

• Health care entities can be sanctioned for failure to report or query (mandatory hospital queries only).

• NPDB information is confidential ($11,000 civil monetary penalty per violation).

• By law, the NPDB must recover full cost of operations. The current fee is $4.75 per query.

44

Healthcare Integrity Healthcare Integrity and Protection Data and Protection Data

Bank (HIPDB)Bank (HIPDB)

45

HIPDB Law and HIPDB Law and RegulationsRegulations

46

HIPDB: Law and RegulationsHIPDB: Law and Regulations

• Established under Section 1128E of the Social Security Act as added by Section 221(a) of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

• Final regulations governing the HIPDB are codified at 45 CFR Part 61.

47

Purpose: To deter fraud and

abuse in the health care system

and to promote quality health care

by collecting and disseminating

final adverse actions taken

against health care practitioners,

providers, and suppliers.

48

HIPDB: Law and RegulationsHIPDB: Law and Regulations(Continued)(Continued)

HIPDB ReportingHIPDB Reporting

49

HIPDB: Who Must Report?HIPDB: Who Must Report?

1. Federal and State Agencies

• Licensing and certification agencies

• Department of Justice, law enforcement agencies, Medicaid Fraud Control Units (MFCUs)

• Department of Health and Human Services (e.g., Centers for Medicare & Medicaid Services (CMS), U.S. Food and Drug Administration (FDA), Office of Inspector General)

• Agencies that administer or pay for the delivery of health care services (e.g., Dept. of Veterans Affairs)

50

HIPDB: Who Must Report?HIPDB: Who Must Report?(Continued)(Continued)

2. Health Plans • Any plan, program, or

organization that provides health care benefits, whether directly or through insurance, reimbursement, or otherwise that take a reportable panel membership action.

51

HIPDB: Overview of what is HIPDB: Overview of what is ReportedReported

1. Health care-related criminal convictions

2. Health care-related civil judgments

3. Exclusions from Federal or State health care programs

4. Federal and State licensure and certification actions

5. Other adjudicated actions or decisions

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53

1. Health care-related criminal convictions include:

• Events related to the delivery of health care items or services;

• When a judgment or conviction is entered against the individual or entity in a Federal, State, or local court;

• When a plea of guilty or nolo contendere by the individual or entity is accepted by a court; and

• When there is a finding of guilt against the individual or entity in court.

HIPDB: What is Reported? HIPDB: What is Reported?

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2. Health care-related civil judgments include:

• Court-ordered actions rendered in a Federal or State court proceeding (not a criminal proceeding);

• Events related to the delivery of a health care item or service, regardless of whether the judgment is the subject of a pending appeal; and

• Government Agencies that are party to a multi-claimant civil judgment

Must assume the responsibility for reporting the entire action

Exception for consent agreements in which there is no finding or admission of liability

HIPDB: What is Reported? HIPDB: What is Reported? (Continued)(Continued)

55


3. Exclusions from Federal or State health care programs include:

• Temporary or permanent debarments of an individual or entity from participation in a Federal or State health-related program (includes the furnishing of items or services)

56


4. Federal and State licensure and certification actions include:

• Final adverse licensure actions taken against health care practitioners, providers, or suppliers;

• Formal or official actions• Revocation or suspension of a license or certification

agreement or contract and the length of any such suspension, reprimand, censure, or probation

• Any loss of license, certification agreement, contract, or the right to apply for or renew a license or certification agreement or contract, whether by operation of law, voluntary surrender, non-renewal (excluding non-renewals due to nonpayment of fees, retirement, or change to inactive status)

57


4. Federal and State licensure and certification actions include:

• Any negative action or finding by Federal or State agency that is publicly available information and is rendered by a licensing or certification authority; and

• Need not be specifically related to professional competence or conduct.


5. Other Adjudicated Actions or Decisions that include due process which*:

• Are formal or official final actions taken against a provider, supplier, or practitioner by a Federal or State Government agency or a health plan; and

• Are based on acts or omissions that affect, or could affect, the payment, provision or delivery of a health care item or service e.g. contract terminations .

*Specifically excludes clinical privileges or panel membership actions

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HIPDB Reports from August 21, 1996 through December 31, 2010

56.6%29.6%

8.7%

3.5%

1.4%0.2%

HIPDB Organization Reports (N=14,300)

Government Administrative: 56.6%, N=8,101State Licensure: 29.6%, N=4,242

Exclusion/Debarment: 8.7%, N=1,238

Judgment or Conviction: 3.5%, N=495

Health Plan Action: 1.4%, N=200


Total Number of Organization Total Number of Organization Reports in HIPDB Reports in HIPDB

59

HIPDB Reports from August 21, 1996 through December 31, 2010

80.3%

13.4%

4.0%

1.2%1.0%

0.1%

HIPDB Practitioner Reports (N=458,404)

State Licensure: 80.3%, N=368,058

Exclusion/Debarment: 13.4%, N=61,449

Judgment or Conviction: 4%, N=18,444

Health Plan Action: 1.2%, N=5,381

Government Administrative: 1%, N=4,434


Total Number of Practitioner Total Number of Practitioner Reports in HIPDB Reports in HIPDB

60

HIPDB Reports By PractitionerHIPDB Reports By Practitioner

Para-Professional Nurses 138,902 Professional Nurses 126,186 Physicians (MDs/DOs) 66,521 Pharmacists and Assistants 27,389 Dentists 18,357 Organization 14,300 Chiropractors 11,284 Non-Health Care Occupations 7,946 Counselors/Marriage/Family Therapists 7,389 Unspecified or Unknown Individuals* 5,843 Social Workers 4,933 Emergency Medical Technicians (EMT) 4,517 Physical Therapists and Assistants 4,428 Respiratory Therapists/Technologists 4,247 Psychologists/Assistants/Associates 3,927 Other Rehab/Restorative Svc. Practitioners 3,295 Podiatrists and Assistants 2,771

Data from August 21, 1996 through December 31, 2010

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HIPDB Reports By PractitionerHIPDB Reports By Practitioner (Continued) (Continued)

Health Care Facility Administrators 2,668 Physicians Assistants 2,636 Other Health Care Occupations 2,542 Other Technologists 2,514 Dental Assistants/Hygienists 2,423 Optometrists 1,840 Occupational Therapists/Assistants 1,337 Other Health Care Practitioners 1,200 Speech/Language Pathologists/Audiologists 1,048 Assistive Devices Service Practitioners 931 Complementary Medicine Practitioners 765 Researchers 318 Dieticians/Nutritionists 145 Medical Assistants 102 Total 472,704

*Reporting entity did not identify Occ/Field of State Licensure Code

Data from August 21, 1996 through December 31, 2010

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HIPDB: Who May Query?HIPDB: Who May Query?

• Federal and State Agencies

• Health Plans

• Practitioners, Providers, Suppliers (self-query only)

• Researchers using non-identifying data only

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HIPDB: Other Provisions HIPDB: Other Provisions OverviewOverview

• Timeframe for reporting is generally within 30 days.

• Civil liability protection is available for all reporters.

• The HIPDB must recover the full cost of operations. (Current fee is $4.75 per query).

64

HIPDB Queries HIPDB Queries

68.0%5.6%

6.0%13.5%

1.8%5.0%

HIPDB Queries (N=11,079,078 )

Health Plans & Insurers - 7,529,462

Other Service Providers - 616,887

State Licensing Agencies - 664,442

Hospitals - 1,496,715

Govt Programs - 204,673

Self Queries - 557,327

65HIPDB Queries from August 21, 1996 through December 31, 2010

Discussion ScenariosDiscussion Scenarios

66

Discussion Scenario:1Discussion Scenario:1

Mercury Hospital’s peer review panel restricts a nurse practitioner’s clinical privileges for 30 days due to concerns about his ability to perform certain procedures safely.

Is this reportable to the NPDB, HIPDB, neither, or both?

67

Discussion Scenario:1 Discussion Scenario:1 AnswerAnswer

ANSWER: Neither

NPDB: Clinical privilege actions/panel membership actions taken against a practitioner other than a physician or dentist may be reported to the NPDB. However, to be reportable, the action must affect the practitioner’s clinical privileges for more than 30 days.

HIPDB: Clinical privilege actions/panel membership actions are not reportable to the HIPDB.

68

Discussion Scenario: 2Discussion Scenario: 2

Greenville Hospital suspends Dr. Zeus’ clinical privileges for 31 days for repeatedly failing to complete medical records. During its investigation, the hospital determined that these failures put patient care at risk.


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Discussion Scenario: 2Discussion Scenario: 2 Answer Answer

ANSWER: Reportable to NPDB

NPDB: The suspension of clinical privileges is in effect for more than 30 days, and the hospital based the action on reasons related to professional competence or conduct that adversely affects or could adversely affect, the health or welfare of a patient.


70

Discussion Scenario: 3

Meadow Behavioral Health Plan’s standard operating procedures require that practitioners be afforded due process when contract actions are taken for cause and that a committee of peers makes all panel membership determinations. After receiving and substantiating complaints about Dr. Aphrodite’s surgical skills, Meadow Behavioral Health Plan removed Dr. Aphrodite from its panel. The Health Plan also took a formal action to terminate Dr. Aphrodite’s contract for cause.


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ANSWER: Both the NPDB and the HIPDB

NPDB: Meadow Behavioral Health Plan’s panel membership action meets the NPDB’s reporting requirements. It was a professional review action based on the practitioner’s professional competence or conduct and adversely affected the practitioner’s panel membership for more than 30 days. (The contract termination is not reportable to the NPDB.)

HIPDB: The contract termination is reportable, as it was a formal action that afforded due process and was based on acts or omissions that affect or could affect the payment, provision or delivery of a health care item or service. (Clinical privilege actions/panel membership actions are not reportable to the HIPDB.)

72


Dr. Mars took a voluntary leave of absence from General Hospital’s medical staff to enter a rehabilitation program for her substance abuse problem. Dr. Mars did not surrender her clinical privileges and the hospital took no action against her.


73


ANSWER: Neither

NPDB: The voluntary entrance of an impaired practitioner into a rehabilitation program is not reportable to the NPDB if no action was taken and the practitioner did not relinquish his or her clinical privileges. If an impaired practitioner is required by a professional review action to involuntarily enter a rehabilitation program, the professional review action is reportable if the action meets the reporting requirements (based on competence/conduct and affects privileges for more than 30 days).

HIPDB: Dr. Mars’ voluntary leave of absence does not meet the reporting requirements of an adjudicated action or decision.

74


The chairman of City Hospital’s cardiology department summarily suspends Dr. Pluto’s clinical privileges for failing to respond to an emergency department call. The summary suspension, which is subsequently reviewed and confirmed by the medical executive committee, is in effect for 60 days. The hospital’s bylaws state that summary suspension decisions by the medical executive committee are considered to be professional review actions.


75


ANSWER: NPDB

NPDB: Summary suspensions that are the result of a professional review action, are in effect for more than 30 days, and are based on professional competence or conduct are considered reportable to the NPDB. Summary suspensions are considered to be final when they become professional review actions through action of the authorized hospital committee or body, according to the hospital bylaws.


76


The Felton Health Plan wins a civil judgment in the amount of $170,000 against a clinical laboratory for submitting claims for services not rendered.


77


ANSWER: HIPDB

NPDB: Civil judgments are not reportable to the NPDB. However, a payment made for the benefit of a health care practitioner in satisfaction of a medical malpractice claim or judgment is reportable to the NPDB.

HIPDB: Federal and State attorneys and health plans must report civil judgments against health care practitioners, providers, or suppliers related to the delivery of a health care item or service, regardless of whether the civil judgment is the subject of a pending appeal.

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Entity RegistrationEntity Registration

79

Entity Registration SecurityEntity Registration Security

Goal is to ensure users accessing the Data Bank are:• Are who they say they are• Are affiliated with the organization on

whose behalf they are assessing the Data Bank

• Enhancing security in compliance with Federal requirements E-Authentication Guidance for Federal

Agencies (OMB M-04-04) Electronic Authentication Guidelines

(National Institutes of Standards and Technology (NIST) Draft Special Publication 800-63-1)

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Reference InformationReference Information

Web Site - www.npdb-hipdb.hrsa.gov

– NPDB and HIPDB Guidebooks– Interactive Training– FAQs, Brochures, and Fact Sheets– Statistics– Annual Reports– Instructions for Reporting and

Querying

Customer Service Center

– 1-800-767-6732 81

Thank you for this Thank you for this opportunity opportunity

to speak with you to speak with you today!today!

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Contact InformationContact Information

83

Elizabeth Rezaizadeh, MPH Public Health Analyst, Division of Practitioner

Data BanksTelephone: 301- 443-2300Email: [email protected]

Documents

Overview of Data Bank Reporting Requirements