Shirley Jones, J.D., M.H.A. U. S. Department of Health and Human Services Health Resources and Services Administration

2. NPDB and HIPDB Statutory Requirements NC AMSS Annual Conference May 13-15, 2009 Shirley Jones, J.D., M.H.A. U. S. Department of Health and Human Services Health Resources and Services Administration Bureau of Health Professions

3. Presentation Overview • Bureau of Health Professions (BHPr) • Mission • Eligibility and Registration • Reporting and Querying • Available Data • Compliance Activities • Proactive Disclosure Service • NPDB Expansion: Section 1921

4. BHPr Mission Increase the population’s access to health care by providing national leadership in the development, distribution and retention of a diverse, culturally competent health workforce that can adapt to the population’s changing healthcare needs and provide the highest quality of care for all

5. Bureau of Health Professions Office of Shortage Designation 2008 Reorganization

6. NPDB-HIPDB Purpose The intent is to protect the public, improve the quality of health care and deter fraud and abuse in the health care system by providing information about past adverse actions of practitioners, providers, or suppliers to authorized health care entities and agencies

7. National Practitioner Data Bank Title IV of Public Law 99-660, the Health Care Quality Improvement Act of 1986, as amended • Part A: Promotion of Professional Activities • Standards for Professional Review Actions • Protection for providing information to Professional Review Bodies • Part B: Reporting Information • National Practitioner Data Bank (NPDB), 45 CFR Part 60

8. Eligibility and Registration • Self-certify eligibility to participate in the Data Banks • MCO must register for both the NPDB and HIPDB • Query: an entity that provides health care services and follows a formal peer review process to further quality health care (NPDB )

9. Eligibility and Registration • Report : • An entity that makes a medical malpractice payment • A State licensing board that takes an adverse action against a physician or dentist • A health care entity that takes an adverse clinical privileging action as a results of a professional review • Professional society that takes an adverse membership action as a result of a professional review

10. NPDB Expansion: Section 1921 • A provision of the Social Security Act as amended by Section 5(b) of the Medicare and Medicaid Patient and Program Protection Act of 1987, as amended by the Omnibus Budget Reconciliation Act of 1990 • Notice of Proposed Rule Making • Published in the Federal Register March 21, 2006 • Projected to be Final in the Fourth Quarter 2009

11. Healthcare Integrity and Protection Data Bank (HIPDB) • Section 1128E of the Social Security Act as added by Section 221(A) of the Health Insurance Portability and Accountability Act of 1996 and its implementing regulations (45 CFR Part 61); opened October 1999 • HIPDB - final adverse actions against healthcare • Practitioners • Providers, • Suppliers, and

12. Eligibility and Registration • State Agency • Federal Agency • Health Plan • Broadly defined

13. NPDB and HIPDB • Administered by Health Resources and Services Administration (HRSA) • Funding • User fees only

14. National Practitioner Data Bank Reporting

15. Medical Malpractice Insurers Self-Insured Organizations State Funds State Medical and Dental Authorities Adverse Licensure Actions Stayed Actions are not reportable Hospitals Other Health Care Entities with formal peer review Who Reports to the NPDB?

16. Who Reports to the NPDB? • Professional Societies with formal peer review • Federal Agencies • Drug Enforcement Agency (DEA) • HHS Office of Inspector General • Health Resources and Services Administration • Indian Health Services • Veterans Hospitals • Department of Defense Health care entities

17. Medical Malpractice Payments Adverse Actions (physicians and dentists) Licensure Clinical Privileges Other practitioners may be reported Professional Society Membership Medicare and Medicaid Exclusions DEA Actions What is Reportable to the NPDB?

18. Medical Malpractice Payments • Any payment, in any amount, made for the benefit of any type of licensed health care practitioner is reportable • Payments by self-insured Health care entity • Payments by insurance companies • Settlements and Judgments • Refund of patient fee is reportable if made by an entity(including a Professional Corporation with a solo practitioner) • Refund of patient fee is not reportable if made by the practitioner from personal funds

19. Who is Reported? A written complaint or claim demanding payment based on a health care practitioner’s provision of or failure to provide health care services • Mandatory for all Health Care Practitioners • Not just for hands-on treatment • Practitioner who performs a referral services, i.e., Department chair • Includes licensed Residents or Interns

20. MMPR: Procedures • Practitioner must be named in both the written complaint or claim demanding monetary payment for damages and the settlement release or final adjudication • Any payment amount • Report within 30 days of the payment • Civil Money Penalty not reporting • $11,000 per event

21. MMPR: Exceptions • “Corporate Shield”̶̶ a payment made as a result of a suit or claim solely against an entity (i.e., hospital, clinic, or group practice) is not reportable • Unlicensed medical or dental students • A payment made for the benefit of a practitioner from personal funds

22. MMPR: Exceptions • A payment made to settle a claim or action is not reportable if the defendant practitioner is dismissed from the lawsuit prior to the settlement or judgment • If the dismissal resulted from a condition in the settlement or release, then the payment is reportable

23. MMPR: Exceptions • A payment made at the low end of a High-Low Agreements is not reportable if: • Agreement is in place prior to the verdict or decision • Fact-finder rules in favor of the defendant and assigns no liability to the defendant practitioner

24. Adverse Action Reports • Hospitals, health plans and other eligible health care entities must report: • Professional review actions that adversely affect a physician’s or dentist’s clinical privileges for a period of more than 30 days • Reporting-mandatory for physicians and dentists

25. Adverse Action Reports • Voluntary surrender or restriction of clinical privileges while under investigation for possible professional incompetence or improper conduct • Voluntary withdrawal of a renewal application • Failure to renew clinical privileges • Voluntary withdrawal of an initial application is generally not reportable to the NPDB • Reporting is discretionary for other health care practitioners

26. Adverse Action Reports • Limitation or reduction of privileges for more than 30 days • Proctoring, mentoring • Summary or precautionary suspension, abeyance • Hospital report within 30 days instead of 15 days?

27. AAR: Procedure • Adverse action related to professional competence and conduct • Report within 30 days of the action date • Clinical privileges are reportable on the 31st day • Sanctions • Loss of immunity protections for 3 years

28. Adverse Action Reports • State Licensure • Medical and Dental Licensing Boards • must report disciplinary actions related to professional competence or conduct • Reportable Actions • Revocation, Suspension, Censure, • Reprimand, Probation, and Surrender • Sanction Licensing Board • Designation of another qualified entity to report

29. Adverse Action Reports • Professional Society Membership • Must report professional review actions that relate to professional competence or conduct that adversely affects the practitioner’s membership • Applies to: • Physicians, • Dentists, and • Other health care practitioners

30. What is in the NPDB? 12/31/2008

31. NPDB: Number of Reports By Practitioner Type 12/31/2008

32. NPDB: Number of Reports By Practitioner Type 12/31/2008 * Reporting entity did not identify Occ/Field of State Licensure code

33. NPDB Expanded Section 1921

34. Major Reports Added by Section 1921 • Adverse licensure actions taken against all health care practitioners, including physicians and dentists • Adds the same type of licensure actions currently reported to the HIPDB • Adverse actions or findings by private accrediting organizations • Adverse actions or findings by non-QIO peer review organizations

35. Section 1921 • Access • Entities that are currently allowed to query the NPDB will have access to Section 1921 reports • Entities given access to the NPDB through Section 1921 will be allowed to query ONLY Section 1921 reports

36. Healthcare Integrity and Protection Data Bank Reporting

37. Who Reports to the HIPDB? • Federal Government Agencies • State Government Agencies • Health Plans

38. What Practitioners are Reported • Health Care Related Actions Against • Licensed Practitioners • Physicians • Dentists • Allied Health Professionals • Providers • Hospitals • Skilled nursing facilities • Suppliers • DMEs

39. What Actions are Reportable? • Licensure Actions • Health care related actions against physicians and dentists that are not related to professional competence and conduct • Health care related actions against all others licensed health care practitioners • Medicare and Medicaid Exclusions • Federal Health Care Programs • State Health Care Programs

40. What Actions are Reportable? • Health Care Related Actions • Criminal Convictions, or • Civil Judgments • Other Adjudicated Actions • Formal or official final action • Availability of a due process mechanism • Acts or omissions that affect or could affect the payment, provision, or delivery of a health care service or item • Temporary actions are not reportable • Summary or emergency actions

41. What is in the HIPDB?Practitioner Reports 12/31/2008

42. What is in the HIPDB?Provider and Supplier Reports 12/31/2008

43. HIPDB: Number of Reports By Practitioner Type 12/31/2008

44. HIPDB: Number of Reports By Practitioner Type 12/31/2008

45. NPDB and HIPDB Physician Reports

46. NPDB-HIPDB: Physician Reports

47. Healthcare Integrity and Protection Data Bank Access to Information

48. Who has Access to the HIPDB? HIPDB • Federal Government Agencies • State Government Agencies • Health Plans • Practitioners, Providers, and Suppliers • Self-query only • Researchers • Non-identifiable statistical information

49. HIPDB Queriers 2008 Total Queries: 1,184,209

50. National Practitioner Data Bank Access to Information