National Practitioner Data Bank: Gray Areas In Reporting
The National Practitioner Data Bank (“NPDB”) is a confidential information clearinghouse created by Congress with the primary goals of improving health care quality, protecting the public, and reducing health care fraud and abuse in the United States.
The NPDB acts primarily as a national flagging system by permitting queriers to perform comprehensive reviews of the credentials of health care practitioners, entities, providers, and suppliers. Hospitals, state licensing boards, and health care entities with formal peer review processes are among some of the few entities permitted to query the NPDB. The NPDB’s reports on health care providers are not publicly available, and even individual health care providers can only run a report on themselves.
In short, the NPDB collects information on medical malpractice payments and certain adverse actions and discloses that information to eligible entities. Entities, such as hospitals, health plans, state and federal law enforcement, state licensing boards, and medical malpractice payers have affirmative reporting obligations under federal law to report certain actions or events about health care providers to the NPDB.
The NPDB uses three report formats to capture the necessary information for report submissions. These report formats are:
- Medical Malpractice Payment Report for reporting medical malpractice payments
- Judgment or Conviction Report for reporting health care-related criminal convictions and civil judgments in federal or state court
- Adverse Action Report for reporting all other actions required to be submitted to the NPDB
1. Medical Malpractice Payments must be reported if:
- If the payment is for the benefit of a health care practitioner in settlement of/satisfaction of a written claim or judgment for medical malpractice;
- If the payment is the result of a written complaint or claim demanding monetary payment for damages; and
- the written complaint or claim must be based on a practitioner's provision of or failure to provide health care services.
2. A judgment or conviction report must be submitted in the following instances:
- When a health care provider is convicted of a federal or state health care related crime (i.e., a crime related to the delivery of health care items or service);
- When a health care provider has been ordered by a civic court to pay a civil judgment in a civil lawsuit related to the delivery of health care related services or other adjudicated actions or decisions; or
- When a final action has been taken against a health care practitioner that meets the following requirements:
- The action was taken by a federal agency, state law enforcement agency, state Medicaid fraud control unit, state agency administering/supervising a state health care program, or health plan;
- The health care provider was provided with a due process mechanism; and
- That final action was based on acts or omissions that affect or could affect the payment, provision, or delivery of a health care item or service.
3. An adverse action report should be submitted in the following instances:
- Adverse clinical privilege action
- Adverse professional society membership action
- State licensure or certification action
- Federal licensure or certification action
- Peer review organization action
- Private accreditation organization negative actions or findings
- Exclusion from participation in federal or state health care programs
Consequences vary depending on which type of entity failed to report an action the NPDB. Consequences are pretty minimal if you are a state or federal agency, while the consequences can be quite severe for private entities. For state and federal law enforcement and state health care related boards, for example, the consequence for not reporting a reportable action to the NPDB is that the name of the entity will be published and made publicly available.
By contrast, any health plan that fails to report information on an adverse action required to be reported to the NPDB will be subject to a civil monetary penalty for each adverse action not reported. A hospital or other health care entity that has substantially failed to submit adverse clinical privileges reports can lose, for 3 years, immunity protections for professional review actions it takes against physicians and dentists based on their professional competence and professional conduct. Finally, any malpractice payer that fails to report medical malpractice payments in accordance with NPDB requirements is subject to a civil money penalty for each such payment involved.
If you are a health care entity with questions about whether an action is reportable to the NPDB, or a provider concerned than an inappropriate report has been submitted about your practice to the NPDB, please reach out to Alex S. Fisher or the rest of the health care service team at Frost Brown Todd. Alex can be reached at (615) 251-5594 or by email at firstname.lastname@example.org.
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Thomas D. Anthony is the former chair of FBT's Health Care Industry Team. He focuses on counseling health care entities on corporate transactions, regulatory compliance and joint ventures.