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National Practitioner Data Bank

Overview

Congress enacted the Health Care Quality Improvement Act, 42 U.S.C. §§ 11101-11152 (HCQIA) in 1986, to improve the quality of medical care by making it difficult for physicians who had been found incompetent from moving from state to state without any record. HCQIA required insurance companies to report medical malpractice payments made; state medical boards to report sanctions; and hospitals to report adverse actions to a national reporting system, the National Practitioner Data Bank (NPDB) (42 U.S.C. §§ 11131-33). Excerpt from Shirley P. Morrigan, Health Care Quality Improvement Act Cases from May 1, 2005 to April 30, 2008, AHLA Seminar Series (June 29, 2008).

Agency Guidance

The NPDB, as a repository for information, collects and releases certain information related to professional competence and conduct of physicians, dentists, and certain other healthcare practitioners. The NPDB receives reports of medical malpractice payments, clinical privileges actions, licensure actions, professional society membership actions, and Medicaid/Medicare exclusions. The NPDB releases this information to hospitals, certain managed care organizations, state licensing boards, professional societies, and other authorized queriers.

The NPDB is a resource to assist state licensing boards, hospitals, and other healthcare entities in investigating the qualifications of the healthcare practitioners they seek to license or hire, or to whom they wish to grant membership or clinical privileges.

Hospitals must query the NPDB whenever a practitioner applies for clinical privileges or medical staff membership. Every twenty-four months, hospitals must query on every practitioner holding clinical privileges or on the medical staff. State licensing boards may query at any time. Certain other healthcare entities such as managed care organizations may query when entering an employment or affiliation relationship with a practitioner. Medical malpractice payers may not query at any time. Healthcare practitioners may self-query at any time. Indeed, it may be in the interest of practitioners to self-query regularly in order to have complete and current knowledge about their NPDB information. Plaintiffs’ attorneys may query under certain limited circumstances. See 45 C.F.R. § 60.11(a)(5).

As to an individual practitioner, it is not the role of the NPDB to determine whether the reporting entity’s decision was correct, wise, or merited. The NPDB ensures that reports are accurate in the limited sense that payments were actually made on behalf of the named practitioners or that adverse actions were actually taken. Similarly, it is not the role of the NPDB to determine whether the reporting entity provided the practitioner adequate due process. All of those issues must be resolved between the practitioner and the reporting entity. However, the reports must accurately describe the actions and reasons the reporting entities took the actions.

The HCQIA requires that reporting entities file reports about reportable actions. DHHS cannot void a report based on the merits of, or lack of the merits of, the case or the fact that the practitioner was not afforded due process. However, there is an important incentive for reporting entities to provide practitioners with due process. Entities that do not provide due process run the risk of losing immunity protection under Part A of the HCQIA. See 42 U.S.C. § 11111(a)(2).

When practitioners are reported to the NPDB, practitioners have the option of disputing the report if they think it is factually incorrect or inconsistent with reporting guidelines. There is an easily accessible procedure online at the NPDB Web site (www.npdbhipdb.com) for disputing reports. The entire dispute resolution process is explained in great detail in the NPDB Guidebook, which can be accessed and downloaded at the Web site.

Moreover, a practitioner can ask that the disputed report be reviewed by the DHHS Secretary. However, a practitioner is first required to attempt to resolve the dispute with the reporting entity. If resolution attempts are unsuccessful, the practitioner may ask that the dispute be elevated to Secretarial Review.

Excerpt from Joyce Ann Brentley, The National Practitioner Data Bank: What It Is and What It Is Not, 5 Physician Organizations 1, 1-2 (Fall 2002).