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New Reporting and Query Rules for the National Practitioner Data Bank

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Richard C. Kraus
M.D. News (Republished in the Foster Swift Health Care Law Report)
February 2010

Beginning on March 1, 2010, new rules will significantly expand the reporting of adverse information about health care practitioners and entities to the National Practitioner Data Bank.  The amendments also allow increased access to the NPDB.  Because of the significant consequences of a data bank entry to physicians and other health care professionals, it is more important than ever to be aware of the reporting and query requirements.

The key changes to the reporting requirements are:

  • State licensing agencies will be required to report adverse actions taken against all licensed health care practitioners.  Under the current rule, only actions against physicians and dentists are reported to the NPDB.
  • State licensing agencies will report administrative fines that are connected to the delivery of health care services.  Currently, fines are only reported if taken in conjunction with other licensing sanctions.  All other sanctions, whether or not based on professional competence or conduct, are reportable.
  • Stand-alone peer review organizations will be required to report negative actions or findings against health care practitioners.  For example, if a peer review organization makes a recommendation that, if adopted, would adversely affect clinical privileges, the recommended sanction is reportable.  The reporting obligations resulting from internal peer review have not changed.
  • Reporting will now be required for adverse licensing actions and negative actions or findings regarding health care entities – not just practitioners.  The term "health care entity" includes hospitals and any entity that provides health care services and engages in professional review activity through a formal peer review process.  Reports about entities will be made by state licensing authorities and private accreditation organizations.
  • Additional information will be included in data bank reports, such as the names of any health care entities with which the practitioner is associated or affiliated.

Existing NPDB reporting requirements for hospitals, other health care entities, professional societies, and medical malpractice payers are not affected by the amendments.

There are also changes regarding access to the NPDB.

  • Under the amended rules, private sector (non-federal) hospitals will now have access to adverse licensure actions taken against all licensed healthcare professionals, not just physicians and dentists.  Access is allowed regarding licensed practitioners in connection with an employment or affiliation relationship or applications for clinical privileges or appointments.
  • Queries about certain information can be made by state health care entity licensure and certification authorities; agencies and contractors administering federal health care programs; state Medicaid agencies; utilization and quality control peer review organizations; and federal and law enforcement agencies.

Entities that are eligible to query the NPDB will continue to query as they always have, but will gain access to additional information.

The amended rules are designed to make NPDB reporting and query rules consistent with those for the Healthcare Integrity and Protection Data Bank (HIPDB), another federally mandated and operated data repository.  Although both data banks have similar purposes, there were significant differences in the types of reportable adverse actions and the individuals or entities with access (federal and state agencies and health plans).  The HIPDB will continue to operate under its current rules.