The ABCs of the National Practitioner Data Bank: What Physicians Should Know

By Andrew C. Harvan, Esq., PAMED’s legal and regulatory analyst


Computer-2-articleThe National Practitioner Data Bank (NPDB) is a government repository that collects, stores, and discloses certain information concerning health care practitioners. Although many physicians may be aware of the NPDB, some of its intricate details may be of particular interest.

A negative NPDB report can have serious consequences for a physician. As a result of information contained in the NPDB, the physician may find their employment opportunities diminished and ability to obtain medical liability insurance hindered. Regardless of whether a NPDB report adequately reflects a physician’s competence, it can be extremely difficult for a physician’s career to fully recover. Thus, it is imperative that physicians understand who can report and what is reportable to the NPDB.  

Here's a closer look at how the NPDB came to be, what actions are reportable, and who can report to and query the NPDB.

A Brief History of the NPDB

Due to a growing public concern that medical liability cases were occurring with increasing regularity, Congress passed the Health Care Quality Improvement Act of 1986 (HCQIA), which can be found at 42 U.S. Code Chapter 117, to counter the frequency of such cases and thereby improve the quality of health care nationwide. Congress theorized that an interstate reporting system that collected and disclosed adverse data on practitioner conduct and competence was needed to restrict practitioners from moving from state to state without disclosure of their previous unprofessional conduct or incompetence.

Under HCQIA, state boards of medical examiners and health care entities are required to report to the U.S. Department of Health and Human Services (HHS) all adverse actions that affect a physician’s clinical privileges for longer than 30 days or a physician’s license. HCQIA also requires that medical malpractice payers report all payments made on behalf of a physician.

Subsequent regulations promulgated by HHS, 45 CFR §60.1 et seq., formally created the NPDB, which became operational in 1990. The Bureau of Health Workforce of the Health Resources and Services Administration (HRSA), an HHS agency, administers the NPDB.

What is Reportable to the NPDB?

The following actions are reportable to the NPDB:

  • Medical Malpractice Payments: Entities that make a payment for the benefit of a health care practitioner in settlement of or in satisfaction (in whole or in part) of a medical malpractice claim or judgment must report payment information to the NPDB. There is no minimum reportable payment amount.
  • Board of Medical Examiners Licensure Actions: Boards of Medical Examiners are required to report adverse licensure actions based on reasons related to professional competence or conduct that:
    • Revoke or suspend a physician’s license;
    • Censure, reprimand, or place on probation a physician;
    • Or under which a physician’s license is surrendered
  • Adverse Professional Society Membership Actions: Professional societies must report professional review actions based on professional competence or conduct which adversely affect the membership of a physician in said society.
  • State and Federal Licensure Actions: Federal and state licensing and certification authorities must report certain actions taken against health care practitioners, providers, or suppliers. These actions include the following:
    • Revocation, suspension, reprimand, censure, or probation of a license, certification agreement, or contract for participation in a government health care program. Such action must be taken as the result of a formal proceeding.
    • Dismissal or closure of a formal proceeding by a licensee resulting in the surrender of a license, certification agreement, or contract for participation in a government health care program, or leaving the state or jurisdiction.
    • Any other loss of a license, certification agreement, or contract for participation in a government health care program, or the right to apply for or renew said license, contract, or agreement.
    • Any other negative action or finding by a federal or state licensing or certification agency that is publicly available information, such as limitations on scope of practice, liquidations, injunctions, and forfeitures.
  • Peer Review Organization Negative Actions or Findings: Peer review organizations must report recommendations to sanction a practitioner. Such recommendations must be the result of formal proceedings.
  • Private Accreditation Organization Negative Actions or Findings: Private accreditation organizations are required to report final determinations of denial or terminations, based on formal proceedings, of an accreditation status that indicates a risk to the safety of a patient, or quality of health care services.
  • Adverse Clinical Privilege: Actions: Health care entities must report adverse clinical privilege actions that are the result of a professional review action and affect a practitioner’s privileges for longer than 30 days. Entities must also report a practitioner who surrenders or otherwise voluntarily restricts their privileges while under investigation, relating to professional competence or conduct, or in return for forgoing such an investigation.
  • Federal or State Health Care-Related Criminal Convictions: Federal, state, and local prosecutors are required to report criminal convictions, regardless of pending appeals, related to the delivery of health care items or services against health care practitioners, providers, or suppliers.
  • Health Care-Related Civil Judgments: Federal and state attorneys as well as health plans are required to report civil judgments related to the delivery of health care items or service

    (regardless of pending appeals) against health care practitioners, providers, or suppliers.

  • Exclusions from Participation in Federal or State Health Care Programs: Federal agencies, state law enforcement agencies, state fraud control units, and state agencies (that administer or supervise state health care programs) must report health care practitioners, providers, or suppliers excluded from participating in federal or state health care programs.
  • Other Adjudicated Actions or Decisions: Federal government agencies, state law, or fraud enforcement agencies, and health plans, must report other adjudicated actions or decisions (such as limitations on scope of practice, exclusions, revocations, suspensions of license) related to the delivery, payment, or provision of a health care item or service against health care practitioners, providers, and suppliers.

Additional information on the reporting of information to the NPDB can be found in 45 CFR Part 60, Subpart B and in Chapter E of the NPDB Guidebook

Who Can Report to and Query the NPDB?

Only certain entities are eligible to report to and query the NPDB. The following entities are eligible to report to the NPDB:

  • Medical malpractice payers
  • Peer review organizations
  • Professional membership societies
  • Hospitals and other
  • health care entities
  • Health plans
  • Private accreditation organizations
  • State licensing boards and boards of medical examiners
  • Federal and state law enforcement agencies
  • Federal and state agencies administering or supervising the administration of federal or state health care programs
  • Federal and state licensing or certification authorities
  • Private entities administering federal health care programs under contract
  • Quality improvement organizations
  • Federal and state prosecutors
  • State Medicaid fraud control units

Hospitals are the only entity required by law to query the NPDB, see 45 CFR §60.17. Hospitals must query the NPDB when practitioners apply for clinical privileges, when practitioners seek to expand existing privileges, and every two years for practitioners on their medical staffs or who have been granted clinical privileges. Additionally, hospitals may query the NPDB for professional review activities. Other health care entities may query the NPDB when making employment, affiliation, or licensure decisions. Practitioners may perform a self-query at any time as well. NPDB data is not available to the public.

Where Can I Find More Information?

Question-Mark-stethescope-articleThe NPDB Guidebook provides guidance and clarification on NPDB guidelines and policies. Published by HRSA, the latest edition of the NPDB Guidebook was released in April 2015. The NPDB Guidebook and other NPDB resources are available online at www.npdb.hrsa.gov.

Pursuant to policy passed at PAMED’s October 2017 House of Delegates, PAMED will oppose any use of the NPDB to manipulate or dissuade physicians from application and participation on medical staffs. PAMED will also provide members with education on the NPDB and its dispute process.

PAMED is currently developing further NPDB resources for its member physicians. These resources include a module on the NPDB dispute process, discussion of steps that can be taken to mitigate the damage of an NPDB report, and education on how to respond to peer review proceedings.

A version of this article appeared in the winter 2018 issue of Pennsylvania Physician Magazine, PAMED’s print magazine, and was reprinted with permission. Look out for an article discussing the NPDB’s dispute process in the next issue of the magazine which will be available in spring 2018.

2 comments

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  1. Andrew Harvan | Mar 23, 2018
    Thank you. Our next article on the NPDB will discuss Subject Statements in greater length.
  2. Malee Maurer | Mar 23, 2018
    Good article.   I have found that many physicians who have a report in the NPDB do not take advantage of the Subject Statement.  (Refer to Chapter F: Subject Statements and the Dispute Process in the NPDB Guidebook.)  This is your opportunity to tell your side.    In my 30+ years of credentialing, it amazes me that so many miss this opportunity.  ~  Malee

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