When it comes to delivering safe healthcare, due diligence in verifying provider eligibility and monitoring various disciplinary databases is crucial for a comprehensive compliance program. When a patient seeks medical attention, they’re trusting that they will not only get the best care but that they’ll be protected while receiving it. One form of patient protection is the National Practitioner Data Bank (NPDB), which protects patients from unfit or excluded practitioners.
What is the National Practitioner Data Bank (NPDB)?
The National Practitioner Data Bank (NPDB) is a confidential information clearinghouse operated by the U.S. Department of Health and Human Services (HHS) and contains medical malpractice payment and adverse action reports on healthcare professionals. Its mission is to enhance healthcare quality, defend the public, and decrease healthcare fraud and misuse in the U.S.
Established by the Healthcare Quality Improvement Act of 1986 (HCQIA), the NPDB protects the public by restricting practitioners’ ability to move around without disclosing medical malpractice payments or adverse action histories. This prevents practitioners from moving from state-to-state or hospital-to-hospital with a hidden record.
During the time of credentialing, employment, licensing, or monitoring, the NPDB serves as an alert or flagging system intended to facilitate a comprehensive review of healthcare practitioners’ professional credentials. The information contained in the NPDB directs discrete inquiry into, and scrutiny of, a practitioner’s licensure, clinical privileges, professional society memberships, and medical malpractice payment history.
Healthcare Legislation & Regulations
Federal legislation and regulations are the foundation of the National Practitioner Data Bank (NPDB). Below are the significant laws and regulations that govern NPDB operations.
- NPDB Regulations
- NPBD Eligible Entities
- Subpart B—CMPs, Assessments, and Exclusions for False or Fraudulent Claims and Other Similar Misconduct
- Subpart C—CMPs, Assessments, and Exclusions for Anti-Kickback and Physician Self-Referral Violations
- Subpart E—CMPs and Exclusions for EMTALA Violations
- Subpart J—CMPs, Assessments, and Exclusions for Beneficiary Inducement Violations
We collaborated with an NPDB expert, Alex Fisher (Attorney, Frost, Brown, Todd) in a previous webinar.
View the Webinar On Demand
What Actions are Reported to the NPDB?
The NPDB collects detailed information about medical practitioners that hospitals and other healthcare entities are sanctioned by law to query.
Organizations that must report adverse information about healthcare practitioners to the NPDB include hospitals, state licensing boards, medical malpractice payers, peer review organizations, and private accreditation organizations.
Entities, including insurance companies, making settlement payments or other payments of a claim or judgment, under an insurance policy, self-insurance, or otherwise, for the benefit of a physician or nurse for medical malpractice.
Federal and state licensing and certification agencies must report specific actions taken against healthcare practitioners, providers, or suppliers. Some of these actions include:
- Revocation or suspension of a license, certification agreement, or contract for participation in government healthcare programs; reprimand; censure; or probation.
- Dismissal or closure of the proceedings because the healthcare practitioner, provider, or supplier surrendered a license, certification agreement, or contract for participation in government healthcare programs, or left the state or jurisdiction.
- A loss of a license, certification agreement, or contract for participation in government healthcare programs, or the right to apply for, or renew, a license, certification agreement.
- Negative actions or findings by a federal licensing or certification agency that is publicly available information, including but not limited to limitations on the scope of practice, liquidations, injunctions, and forfeitures.
Hospitals and other healthcare entities must report any professional review action that adversely affects the clinical privileges of a physician or dentist for a period of more than 30 days or the acceptance of the surrender of clinical privileges, or any restriction of such privileges by a physician or dentist, (1) while the physician or dentist is under investigation by a healthcare entity relating to possible incompetence or improper professional conduct, or (2) in return for not conducting such an investigation or proceeding.
Professional societies must report professional review actions based on professional competence or conduct that adversely affects the physician’s membership in the society.
Peer review organizations must report recommendations to approve a practitioner. Such recommendations must be the result of legal procedures.
Private accreditation organizations must report final determinations of denial or terminations, based on formal proceedings, of an accreditation status that indicates a risk to a patient’s safety or quality of healthcare services.
In addition to health plans, federal and state attorneys must report civil judgments related to delivering healthcare items or services against healthcare practitioners, providers, or suppliers.
Federal agencies, state law enforcement agencies, state Medicaid fraud control units, and state agencies administering or supervising a state healthcare program must report health care practitioners, providers, or suppliers excluded from participating in federal or state healthcare programs.
Only the state agency that takes action to exclude a healthcare practitioner, provider, or supplier is responsible for reporting that action.
Federal agencies, state law or fraud enforcement agencies, plus health plans must report other adjudicated actions or decisions against health care practitioners, providers, and suppliers.
Among the specified state agencies, only the state agency that takes an adjudicated action or decision against a healthcare practitioner, provider, or supplier is responsible for reporting that action.
Who Can Search the NPDB?
The NPDB is prohibited by law from disclosing information on a specific practitioner, provider, or supplier to the general public. However, hospitals, state licensing boards, professional societies, other healthcare eligible entities, and plaintiffs’ attorneys are all permitted to query the NPDB under specific conditions.
Also, individuals may query their own records. Hospitals are the only health care entities with a mandatory requirement for querying the NPDB. During the employment process (and every two years), a hospital must request information on prospective healthcare practitioners.
Healthcare Exclusion and Sanction Monitoring
As a reminder, exclusion screenings are conducted to verify that a potential employee is not classified as an excluded individual, who has been excluded from participation in any federal healthcare program. A healthcare sanction is an administrative action taken against an individual or a state professional licensure board license. Such sanctions can be attributed to a restriction placed upon a license and can include a revocation of the license.
Healthcare organizations must have a comprehensive plan to screen their providers and affiliates against various exclusion lists. This should be done at least at the time of employment and once a month thereafter. Here are some exclusion stories about healthcare bad actors to help you understand the significance of fraud, waste, and abuse in federal programs.
The best practice for finding exclusions and sanctions in addition to referencing the NDPB is to search the OIG LEIE and SAM.gov websites and all available state Medicaid exclusion lists. This practice will ensure that you are not employing or contracting with an excluded person or entity.
We’ve made it easy to reference healthcare exclusion data all from one convenient location. Check out our interactive exclusions map to see how many exclusions are present from the OIG LEIE, SAM.gov, and all state Medicaid excluded, sanctioned, or terminated provider lists.
Building a Safer and Smarter Healthcare
To feel secure, patients need to know that healthcare organizations did everything they could to keep them safe, including carefully monitoring their practitioners, providers, and vendors. At ProviderTrust, we pride ourselves on piecing together comprehensive datasets to create a full profile of a large population of healthcare providers and licensed clinicians.
In this way, we are able to fill in missing information that either you are not capable of obtaining, or may not have the time and resources to devote to aggregating yourself. Our software solutions provide a broader context of information, including sanctions and disciplinary actions for individuals that they may not disclose to you until it’s too late.
When it comes to hiring and monitoring the best quality of staff for your organization or referral network, a smarter monitoring process is key to eliminating bad actors from your organization. By combining NPDB information and a comprehensive exclusion monitoring program, you will be able to reduce risk and keep patients safe.