By Mercedes L. Varasteh
All physicians should be familiar with the National Practitioner Data Bank (“NPDB”), the online clearinghouse for information about medical practitioners’ history.  However, not all physicians may be aware of the types of occurrences that can be properly reported to the NPDB and thus dramatically impact credentialing opportunities.  While the NPDB is not accessible by the public at large, information in the data bank is available to state licensing boards, hospitals and other health care entities (such as HMOs and PPOs), professional societies, and certain federal agencies such as the Health and Human Services Office of the Inspector General (HHS-OIG).

Background on the NPDB

The NPDB was originally launched as part of the Health Care Quality Improvement Act of 1986 (HCQIA).  The HCQIA was passed by Congress to prevent incompetent practitioners from relocating state to state by creating a mechanism to disclose evidence of harmful or incompetent performance.  Legislators also hoped that the creation of a central database would encourage states, hospitals, and professional societies to report adverse actions taken against practitioners.  In 1990, the NPBS began officially collecting reports on medical malpractice payments and adverse licensure, clinical privileges, and professional society membership actions.

In 1997, the NPDB was required to coordinate operations with the new Healthcare Integrity and Protection Databank (“HIDPD”), which was designed to prevent healthcare fraud and abuse.  The HIPDB is a national collection program for reporting and disclosing certain final adverse actions taken against health care providers, practitioners, and suppliers, such as exclusions from Medicare or Medicaid programs.  By law, the NPDB and HIPDB were required to coordinate operations, so that information reported to the HIPDB would also appear on the NPDB and vice-versa.

Modern technology has enabled the NPDB-HIPDB to be accessed or “queried” swiftly and easily by eligible entities, such as hospitals, medical examination or other state licensing boards, health care entities, and professional societies.  When NPDB originally began collecting physician reports back in 1990, all transactions were paper-based and a query response time averaged around six weeks.  Now, all queries and submissions are conducted on-line and the average query response time is less than one hour.

The advent of technology now means that information about physicians can be quickly disseminated to health care entities across the county.  Furthermore, all reports made to the NPDB are permanent and will not be “expunged” after the passage of time.  A correction or void submitted by the reporting entity is the only way to remove information from a physician’s profile.

There are three key types of information reportable to the NPDB: 1) medical malpractice payments; 2) adverse clinical privilege actions; and 3) exclusions from Medicare/Medicaid and other federal programs.  This article will address the first two most common groups of reportable information.

Medical Malpractice Payments

NPDB guidelines require that any kind of medical malpractice payment made on behalf of a physician, dentist, or other health care practitioner in settlement or in satisfaction (in whole or in part) of a claim or judgment against that practitioner be reported.  This encompasses claims based on substandard care, professional incompetence, or professional misconduct.  The report must include a detailed narrative describing the patient (age, sex, medical condition, etc.) and the alleged acts or omissions upon which the medical malpractice claim is based.  If a practitioner is dismissed from a lawsuit prior to the settlement of judgment, any payment made to the plaintiff is not reportable.  In addition, payments made by the practitioner in a personal capacity are not reportable.  However, if the dismissal from a lawsuit is a condition of a settlement or release, then the payment is reportable.  Thus, it is important for physicians to carefully monitor all malpractice litigation (even if payments are to be made by the hospital or insurance carrier) and to obtain early dismissal before settlement negotiations are undertaken.  A physician is well-advised to engage a personal attorney for such purpose.

What Kinds of Adverse Clinical Privileges Actions Are Reportable

While most physicians probably know that the revocation of clinical privileges is reportable, there are several nuances to keep in mind.  For example, even in situations where a physician voluntarily surrenders or withdraws his request for clinical privileges, this can still be reported to the NPDB if the surrender/withdrawal follows an investigation of professional competence or conduct or is made in exchange for not investigating a physician’s conduct.

To take this example a step further, suppose Dr. Smith is a physician at a hospital with privileges in pulmonary care.  Dr. Smith is privately planning on relocating to a new state in the near future, so he does not renew his clinical privileges at the hospital.  Unbeknownst to Dr. Smith, the Hospital is investigating him based on an allegation by another staff physician that Dr. Smith has a substance abuse problem and is a threat to patient safety.  Even if the allegation turns out to be false, and even if Dr. Smith has no idea that he is being investigated, his failure to renew his clinical privileges while under investigation is a reportable event.  This is because a practitioner’s awareness that an investigation is being conducted is not a requirement for reportability.

            Other examples of reportable adverse actions include:

-         Summary suspension if lasting more than 30 days and based on professional competence or conduct.  (Adverse actions involving censures, reprimands or admonishments are not reportable to the NPDB.)

-         Denial of an initial application for clinical privileges, if the denial is the result of a professional review action related to professional competence or conduct.

-         Granting of clinical privileges that are more limited than those requested, if the limitation is the result of the practitioner’s professional competence and conduct.  

-         Non-renewal of clinical privileges, if based on professional competence or conduct.  (The non-renewal of clinical privileges is not reportable if based on facility resources or a change in the institution’s threshold eligibility criteria).

-         Reduction or revocation of clinical privileges, even without demotion or dismissal, if related to professional competence and conduct.

-         Reduction or revocation of privileges combined with demotion or                       dismissal, if based on professional competency or conduct.

In order to avoid having unfavorable reports issued to the NPDB, physicians should fully exercise their fair hearing/due process and appeal rights under medical staff bylaws and procedures/policies. All disputes regarding reported information must be handled through the reporting entity, not through the NPDB.  In addition, adverse actions on clinical privileges are not reportable until they are made final by the health care entity, meaning that the physician has received a hearing and completed the appeals process as provided for by the hospital bylaws.  (An exception applies if summary suspension or restriction subject to later notice and hearing is enforced because of an imminent threat to a patient’s health and safety).  In addition, if a report of adverse action has already been made to the NPDB, the physician can still appeal the report as provided by the hospital bylaws and/or policies and procedures.  Although practitioners with reports in the NPDB may add statements to the reports, which will be disclosed to queries, it is more effective to simply reduce the chances of such a report being made.

Conflicts do arise in hospital settings and physicians may be subjected to adverse action for simply refusing to take action which, in their opinion, deviates from the standard of care or for innocently reporting what they believe to be improper procedures within the hospital (suspicious billing activity, failure to maintain complete medical records, etc.)  These physicians can be branded as “troublemakers” and forced to endure unfair suspensions, probations, or adverse actions to clinical privileges. Physicians who feel adverse action has been taken against them should consult with an experienced health care attorney to protect any rights they may have and to prevent damaging reports about them being made to the NPDB.