By Andrew C. Harvan, Esq., PAMED’s legal and regulatory analyst
This article is the first part of an article series on the National Practitioner Data Bank (NPDB). Part 2 in the series discusses how to dispute an NPDB report. Read Part 2.
The 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:
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.
Eligible entities can only query for specified reasons provided for in the NPDB regulations. If an entity fails to make a NPDB report when required to do so, the entity could be subject to civil money penalties.
Where Can I Find More Information?
The 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.