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Why the National Practitioner Data Bank Matters to You and Your Clients

Why the National Practitioner Data Bank Matters to You and Your Clients. Mark V. Gende, Esq. Sweeny, Wingate & Barrow, PA Columbia, South Carolina. What is the NPDB?. Information clearing house Collect and release certain information Professional competence and conduct Physicians Dentists

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Why the National Practitioner Data Bank Matters to You and Your Clients

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  1. Why the National Practitioner Data Bank Matters to You and Your Clients Mark V. Gende, Esq. Sweeny, Wingate & Barrow, PA Columbia, South Carolina

  2. What is the NPDB? • Information clearing house • Collect and release certain information • Professional competence and conduct • Physicians • Dentists • Other health care practitioners

  3. Why did Congress Create NPDB? • Increasing medical malpractice litigation • Need to improve quality of medical care • National problem states unable to address • Restrict incompetent physicians movement • Promote effective peer review by • Incentives (fines) • Protection (confidentiality) • Reduce health care fraud and abuse (NIPDB)

  4. A Brief History of the NPDB • Health Care Quality Improvement Act of 1986 (Title IV) • Medicare and Medicaid Patient and Protection Act of 1987 (Section 1921; NPDB) • Health Insurance Portability and Accountability Act of 1996 (Section 1128E; HIPDB) • Patient Protection and Affordable Care Act of 2010 (merge NPDB and HIPDB)

  5. The Merger of NPDB and NIPDB • NIPDB consolidated with NPDB May 6, 2013 • Final regulations published April 5, 2013, Codified at 45 CFR Part 60 • Draft NPDB Guidebook published November 2013 • Comment period on Revised NPDB Guidebook closes on February 5, 2014 • New NPDB Guidebook will be posted at http://www.npdg.hrsa.gov

  6. What about the NPDB isimportant to litigators? • Basic reporting requirements • Basic querying access • Where you are likely to encounter the NPDB • The NPDB web site

  7. Basic Reporting • Who is reported? • Physicians • Dentists • Other practitioners • Entities • Providers • Suppliers

  8. Basic Reporting • Who reports? • Medical malpractice payers • Hospitals • Other self-insured healthcare entities • Professional societies • Health plans • Peer review organizations • Various State and Federal agencies

  9. Basic Reporting • What is reported? • Medical malpractice payment from • A written claim • A judgment • Certain adverse clinical privileges actions • Certain adverse professional society membership actions • DEA controlled substances registration actions • Exclusions from Medicare, Medicaid

  10. Basic Reporting • When is a report made? • Within 30 days from • Date action taken • Date payment made • What are the basic report formats? • Medical Malpractice Payment Report (MMPR) • Judgment or Conviction Report • Adverse Action Report

  11. Basic Reporting • What is in a report? • Age of claimant • Sex of claimant • Patient type (in or out) • Initial Event (medical condition of patient) • Procedure performed • Claimant’s allegation • Associated legal and other issues • Outcome

  12. Basic Reporting • Example of a MMPR A 65-year-old male outpatient had a prostate exam by Dr. A. Six months later, the patient was diagnosed by Dr. B with prostate cancer and underwent surgery. One year later, the patient sued Dr. A for alleged failure to diagnose. A settlement was reached in the amount of $250,000. (Source: NPDG Guidebook, September 2001)

  13. Basic Querying • What is querying? • Ability to access NPDB reports • Who must/may/may not query? • Hospitals (must) • State licensing boards • Professional societies • Other health care entities • Attorneys • Physicians, dentists, practitioners concerning self • Medical malpractice payers (cannot)

  14. Attorney Querying • Plaintiffs’ attorneys • Filed medical malpractice action/claim • Against hospital • Evidence reveals hospital failed to query • Practitioner also named in the action/claim • Defense attorneys • Not permitted to query • Defendant practitioner can self-query

  15. NPDB and the Litigator • Advise your client early about NPDB reporting • As it relates to settlement • As it relates to reporting • Memorialize your advice • Clients surprised by NPDB reporting • File grievances • May impact representation opportunities • With other medical providers • With your carrier

  16. NPDB and the Litigator • Carrier asks you to draft the report • Consult the Guidebook • Coordinate draft with carrier • Coordinate draft with client • Memorialize all communications

  17. NPDB and the Litigator • Challenging a filed report • Retained by a practitioner • Well defined appeals process • Typically courts have upheld the NPDB

  18. Leaning More about the NPDB • The Draft NPDB Guidebook • The U.S. Department of Health and Human Services web site • http://www.npdb.hrsa.gov • Wealth of interesting statistical information • Statistical Data / NPDB research statistics

  19. United States

  20. South Carolina (all practitioners)

  21. South Carolina (physicians)

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