By: Kelli Robinson, Kelli is a member of the Health Care Law Consulting Group at Sirote & Permutt, P.C. She also serves as a hearing officer for the Board of Dental Examiners of Alabama.
Most healthcare practitioners have heard of the National Practitioner Data Bank (NPDB), but many are unfamiliar with exactly what it is, how it operates, and what implications it might have on a healthcare practitioner’s career. The NPDB acts as a national clearinghouse for information relating to the professional competence of healthcare practitioners, and it is administered by the Health Resources and Services Administration (HRSA), a division of the United States Department of Health and Human Services (HHS).
The information reported to the NPDB is intended to be used in combination with information from other sources in making determinations on employment, affiliation, clinical privileges, certification, licensure, or other decisions. Hence, if the name of a physician or dentist, or other healthcare practitioner, is found in the NPDB, it could affect the ability of that healthcare practitioner to obtain privileges with a hospital or a state license.
On April 6, 2015, the HRSA released a revised NPDB Guidebook - the first update in more than ten years. An electronic copy of the 2015 NPDB Guidebook can be found on the NPDB web site (www.npdb.hrsa.gov).
Queries
The 2015 NPDB Guidebook contains detailed information about what entities and individuals must or may query the NPDB, including information about the type of information available to the specific entities or individuals and how the specific entities and individuals are permitted to use the information they obtain from the NPDB.
Following are two examples of federally-mandated queries of the NPDB:
• Hospitals are required to query the NPDB when a physician, dentist, or other healthcare practitioner applies for medical staff appointment (courtesy or otherwise) or for clinical privileges at the hospital, including temporary privileges.
• Every two years, hospitals are required to query the NPDB on all physicians, dentists, and other healthcare practitioners who are on its medical staff (courtesy or otherwise) or who hold clinical privileges at the hospital.
Other healthcare entities may query the NPDB when they have or may be entering into employment or affiliation relationships with healthcare practitioners; when healthcare practitioners apply for clinical privileges or medical staff appointments; and/or when they are engaging in professional review activity.
Entities like health plans and state licensing and certification agencies also may query the NPDB when they are determining the fitness of individuals to provide healthcare services; when they are protecting the health and safety of individuals receiving healthcare through programs they administer; and/or when they are protecting the fiscal integrity of programs they administer.
Practice Pointer: A healthcare practitioner may self-query the NPDB at any time by submitting a request through the NPDB web site (www.npdb.hrsa.gov) and paying a small fee (currently $5.00). Healthcare practitioners should regularly request a NPDB self-query to ensure all information in the data bank is correct. If any inaccurate information is discovered, promptly follow the steps below to correct or dispute the NPDB report.
Reports
NPDB reporting requirements by entity are set forth in detail in the 2015 NPDB Guidebook. Below is a summary of the information required to be reported to the NPDB:
• Medical malpractice payments resulting from a written claim or judgment;
• Certain adverse licensure actions related to professional competence or conduct;
• Certain adverse clinical privileges actions related to professional competence or conduct;
• Certain adverse professional society membership actions related to professional competence or conduct;
• DEA controlled substances registration actions;
• Exclusions from participation in Medicare, Medicaid, and other Federal health care programs;
• Negative actions or findings by peer review organizations;
• Negative actions or findings by private accreditation organizations;
• Exclusions from participation in State health care programs;
• Health care-related civil judgments in Federal or State court;
• Health care-related Federal or State criminal convictions;
• Federal licensure and certification actions; and
• Other adjudicated actions or decisions.
Information reported to the NPDB is maintained permanently unless it is corrected or voided from the system.
Practice Pointer: Healthcare practitioners at risk of being reported to the NPDB should immediately consult with experienced legal counsel to assess whether there are opportunities to avoid a report to the NPDB. Even when a NPDB report must be made by a reporting entity, legal counsel can help mitigate the adverse consequences of a report by negotiating the wording of the report, as well as classification codes and basis of action codes.
Subject Statements and the Dispute Process
When the NPDB processes a report, the NPDB notifies the subject of the report. The notification provides instructions for obtaining an official copy of the report from the NPDB web site.
The subject of a report submitted to the NPDB should review the report for accuracy, including the description of the reported event. If any information in the report is inaccurate, the subject of a report can request that the reporting entity file a correction. The NPDB is prohibited by law from modifying any submitted information, even if the healthcare practitioner who is the subject of the information can prove its inaccuracy.
If a reporting entity refuses to change the report it submitted to the NPDB, the affected healthcare practitioner may initiate a dispute to the NPDB and/or add a statement to the NPDB report, which any subsequent requestor would receive. The dispute process allows a healthcare practitioner to protest the factual accuracy of the report or whether the report was submitted in compliance with the NPDB reporting requirements. A healthcare practitioner, however, is prohibited from disputing the underlying reasons for the reports, such as the merits of a medical malpractice claim or the appropriateness of, or basis of, other types of reports.
Practice Pointer: A healthcare practitioner should seek the assistance of experienced legal counsel before determining the best way to respond to an inaccurate NPDB report, including contacting the reporting entity directly, drafting a subject statement for inclusion with the NPDB report, and/or navigating the NPDB dispute resolution process.
Conclusion
Reports to the National Practitioner Data Bank can have a significant impact on a healthcare practitioner’s future. Therefore, it is important for healthcare practitioners to understand how the National Practitioner Data Bank operates, as well as the healthcare practitioner’s rights with respect to the information reported, how information is reported, who is allowed access, and what can be done to ensure the accuracy of the information in the National Practitioner Data Bank. Finally, healthcare practitioners must be aware of which types of adverse actions will be reported to the National Practitioner Data Bank and should take care to mitigate any potential future impact.
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