Florida Association of Nurse Practitioners
August 7, 2015
Margarita Morales, MS
U.S. Department of Health and Human Services
Health Resources and Services Administration
Bureau of Health Workforce
Division of Practitioner Data Bank
Presentation Overview
• National Practitioner Data Bank (NPDB) General
Provisions
• Reporting and Querying Details
o Reporting and Querying Overview
o Hospital Querying
o Hospital Reporting
o Report Subjects
o Potential Hospital Sanctions
o Continuous Query
•
NPDB Compliance
•
NPDB Guidebook
•
Resources
•
Contact Information
2
General Provisions
Purpose
Created under three statutes
to meet several needs:
• Flagging system for
effective credential
reviews
• Protection against unfit
practitioners
• Deter fraud and abuse in
the health care system
3
General Provisions
Merger Goal:
Eliminate duplication between the NPDB and HIPDB
• The 3 statutes-- Title IV of Public
Law 99-660, Section 1921 of the
Social Security Act, and Section
1128E of the Social Security Act -remain in effect
• ONE data bank
• ONE set of regulations governing
the NPDB’s operations
4
General Provisions
Types of Information Collected
• Medical malpractice judgments, settlements
• Adverse licensing, certification actions
• Clinical privileges actions
• Health plan contract terminations
• Professional society membership actions
• Negative actions/findings from private accreditation
organizations and peer review organizations
• Government administrative actions, e.g., exclusions
from programs
• Civil & criminal health care-related judgments
5
General Provisions
Types of Transactions
• Reporting (no charge)
• Querying (by hospitals and health care
organizations)
o $3 for a one-year continuous query
subscription
o $3 for a one-time query
o Fees lowered October 1, 2014
• Self-Query (by an individual or organization)
o $5
o Fee lowered October 1, 2014
6
General Provisions
Recovering Costs
• By law, the NPDB must recover the
full cost of operations. It does so by
collecting fees for each query.
Confidentiality
• Information reported to the NPDB is
confidential, not available to the
general public, and may not be
disclosed except as provided by law.
• Penalty up to $11,000 per
confidentiality violation.
7
General Provisions
Civil Liability Protection
• Immunity provisions in Title IV, Section
1921, and Section 1128E protect
individuals, entities, and their authorized
agents from being held liable in civil actions
for reports made to the NPDB unless they
have actual knowledge that the information
in the report is false.
• Health care entity professional review
bodies, their members, and their agents
are immune from civil liability in most
cases.
8
Reporting and Querying
Details
9
Reporting and Querying Overview
ENTITY TYPE
Hospitals
Health plans
Other health care entities with formal peer review
State agencies that license and certify health care practitioners and entities,
including boards of medical and dental examiners
State agencies administering or supervising state health care programs
State law enforcement or fraud enforcement agencies (including state
Medicaid fraud control units and state prosecutors)
Federal licensing and certification agencies
Agencies administering federal health care programs, including private
entities administering such programs under contract
Federal law enforcement officials and agencies (including Drug Enforcement
Agency, HHS Office of Inspector General, and federal prosecutors)
Medical malpractice payers
Professional societies with formal peer review
Peer review organizations (excluding quality improvement organizations)
Private accreditation organizations
Quality improvement organizations
Individual practitioners, providers, and suppliers (self-query only)
Required
Not Authorized
Optional
REPORT QUERY
10
Hospital Querying
Must query on: Health care practitioners when
practitioners apply for staff appointments (courtesy or
otherwise) or clinical privileges (including temporary
privileges); every two years for practitioners on staff or
with clinical privileges
May query on: Health care
practitioners with whom the
hospital has entered (or maybe
entering) employment or affiliation
relationships
11
Hospital Querying
• Centralized
Credentialing
• Querying Through an
Authorized Agent
• Delegated Credentialing
• Continuous Query
12
Hospital Reporting
Overview
• Must report on: Physicians and dentists
o Adverse clinical privileges actions >30 days related to
professional competence or conduct
• May report on: Other practitioners
o Adverse clinical privileges actions >30 days related to
professional competence or conduct
13
Hospital Reporting
• Denials, reductions, and
restrictions of privileges
• Withdrawals and Nonrenewals
• Summary suspensions
• Report forwarding to State
Licensing Boards
• Investigations
o “While under investigation or
in return for not conducting
such an investigation”
14
Potential Hospital Sanctions
Failure to Report
Loss of immunity protections provided for
professional review activities that occur during the
3-year period and organization name published in
the Federal Register
Failure to Query
Plaintiff is allowed access to
NPDB information on that
practitioner for use in litigation
against the hospital.
15
Report Subjects
Approximate Number of New NPDB Reports Submitted
On Individual Subjects From 2010 – 2014 by Profession
Registered Nurses
128,000
Licensed Practical/
Vocational Nurses
82,000
Optometrist/
Optician
1,500
Social Workers
4,500
Podiatrist
2,500
Psychologist
2,500
Chiropractors
6,500
Other Behavioral
Health
7,500
Total: ~482,500
Reports
Advanced Practice
Nurses
5,000
Pharmacists/Pharmacy
Technicians
27,000
Physician
Assistants
3,500
Emergency Medical
Technician
5,500
Nurse Aides/Nursing
Assistants/Home Health Aides
55,500
Dentists
19,000
Physical/Occupational/
Respiratory/Massage
Therapists/Assistants
14,500
Physicians
95,500
Other Individual Subjects
21,000
Other Technologist/
Technician
1,000
16
Reports by Profession
1.94%
2.67%
2.75%
2.83%
0.72%
0.61% 0.60%
NPDB Reports by Profession
Physician-MD: 36.9%, N=405,685
0.60%
0.4%
1.07%
Registered Nurse: 15.4%, N=168,641
Licensed Practical Nurse: 9.6%, N=105,774
0.34%
Nursing Para-Professionals: 8.2%, N=90,236
Dentist: 7.3%, N=79,736
2.84%
Other: 5.3%, N=58,058
36.92%
5.28%
Physician-DO: 2.8%, N=31,223
Therapists and Counselors: 2.8%, N=31,126
7.26%
Pharmacist: 2.8%, N=30,198
Technicians and Assistants: 2.7%, N=29384
8.21%
Chiropractor: 1.9%, N=21,310
9.63%
15.35%
Podiatrist: 1.1%, N=11,762
Social Worker: 0.7%, N=7,889
Physician Assistant: 0.6%, N=6.707
Adv. Practice Nurse: 0.6%, N=6,559
Psychologist: 0.6%, N=6,580
Dental Asst/Hygienists: 0.4%, N=4,116
Ocularist/Optician/Optometrist: 0.3%, N=3.709
NPDB Reports from September 1, 1990 through December 31, 2013 (2014Q2 IAF file)
Continuous Query
18
Continuous Query
Purpose
• A subscription service that notifies
subscribers of new information on any of
their enrolled practitioners within one
business day of the NPDB’s receipt of
the information
• Designed and developed to help meet
new accreditation standards that require
ongoing monitoring of practitioners
• Since 2007, health care providers have
enrolled more than 1.85 million
practitioners
19
Continuous Query
With One-Time Query
With Continuous Query
• An average of 320 days
pass between receipt of a
report and disclosure of the
report in response to a
query.
• Service notifies subscribers
of a report on their enrolled
practitioners within one
business day of receipt by
the NPDB
• Re-credentialing means requerying practitioners and
reviewing all results to
identify new information – a
tremendous amount of
effort for large
organizations.
• By handling new reports as
they are disclosed,
subscriber organizations are
always up to date.
Subscribers can deal only
with events that need
attention, immediately
resolving issues
20
Continuous Query
Using Continuous Query
• Requires the same practitioner information
• Subscribers continue using their subject databases
• Fee: $3.00 per enrollee per year
• No separate query fee
• Upon enrollment, receive the same report information as
a one-time query response
• Continuously queries the NPDB and notifies subscribers
of any new reports
• No need to re-query for reappointments or temporary
privileges extensions
21
Continuous Query
Endorsements
• The Joint Commission
• National Committee for Quality Assurance (NCQA)
• Commission on Accreditation of Rehabilitation
Facilities (CARF)
• Utilization Review Accreditation Commission (URAC)
• Centers for Medicare & Medicaid Services (CMS)
Using Continuous Query helps meet obligations imposed by
the Health Care Quality Improvement Act of 1986 (HCQIA).
22
NPDB Compliance
23
NPDB Compliance
• To date, NPDB compliance activities have
focused primarily on licensing boards
• Licensing board process updated in January
2015
• Currently shifting attention to other areas, in
addition to ongoing licensing board efforts:
o Medical malpractice
o Health plans
o Judgments/Convictions
o Hospitals
• Increased focus on improving NPDB registration
data and overall data integrity
24
NPDB Compliance
State Board Adverse Action Comparison Impact (As of Dec. 2014)
6,713
7,000
6,000
5,000
3,266
4,000
6,078
Other Professions
Physicians
3,000
1,781
2,000
940
1,000
571
369
635
1,485
0
New Reports
New Reports Disclosed
Total Disclosures from
New Reports
- New Reports are those submitted with effective dates during the time period being reviewed (2010-2012) and concurrent with the
compliance effort
- New Reports Disclosed represents the number of New Reports that have been disclosed as of December 2014 to queriers
- Total Disclosures from New Reports represents the number of times the New Reports have been disclosed as of December 2014
to queriers
25
NPDB Compliance
2013-2014 State Board Attestation
Results (as of Dec. 2014)
Professions Failed to
Attest
8.86%
Professions Could Not
Attest
8.00%
2010-2012 State Board Adverse Action
Comparison Results (as of Dec. 2014)
Professions Under
Review
1.21%
- Attestation occurs for each board every two years at
registration renewal
- Profession refers to state/profession combinations
- Could Not Attest indicates a statement by the board that it
could not attest that all reports have accurately been
submitted
- Failed to Attest indicates the board failed to provide a
response for the profession
Professions NonCompliant
1.02%
Total Professions Reviewed = 1,574
Total Attestation Professions = 1,050
Professions Attested
83.14%
Professions Working
Towards Compliance
0.95%
Professions Compliant
96.82%
- Review completed for the 12 most queried professions (i.e.,
nurses, pharmacists, physician assistants, podiatrists,
psychologists, social workers, physicians, dentists,
chiropractors, optometrists, physical therapists, and
behavioral health professionals) in each state. Allied health
professions (e.g., pharmacy technicians, nursing assistants,
dental hygienists) were also included.
26
NPDB Reports
Florida APRN vs. Physician
NPDB Research Statistics:
http://www.npdb.hrsa.gov/resources/npdbstats/npdbStatistics.jsp
27
Adverse Action by Report
Type - Florida APRN
Stahl, Anne L. National Practitioner Data Bank. Location by Payment Year. Generated using the Data Analysis Tool at
http://www.npdb.hrsa.gov/analysistool. Jun 05, 2015. Data source: National Practitioner Data Bank (2013): Adverse Action and Medical Malpractice
Reports (1990-2013)."
28
Adverse Action &
Malpractice Payment- Florida APRN
Stahl, Anne L. National Practitioner Data Bank. Location by Payment Year. Generated using the Data Analysis Tool at
http://www.npdb.hrsa.gov/analysistool. Jun 05, 2015. Data source: National Practitioner Data Bank (2013): Adverse Action and Medical Malpractice
Reports (1990-2013)."
29
Malpractice Payment Totals
Florida APRN
Stahl, Anne L. National Practitioner Data Bank. Location by Payment Year. Generated using the Data Analysis Tool at
http://www.npdb.hrsa.gov/analysistool. Jun 05, 2015. Data source: National Practitioner Data Bank (2013): Adverse Action and Medical Malpractice
Reports (1990-2013)."
NPDB Compliance
Attestation
Required at NPDB registration renewal for all boards
licensing or certifying health care professions.
Attestation has three parts:
• Review and update agency’s profile to reflect changes
over the last two year period.
• Profession Verification: agencies review, verify, and
update the list of professions they currently regulate.
• Certification: all agencies attest to their compliance
with NPDB reporting requirements for each of their
regulated professions.
31
NPDB Compliance
Audit of Board Actions
• One-to-one audit of all professions representing
80% of query volume
o Physicians (MD and DO)
o Dentists
o Physician Assistants
o Advanced Practice Nurses
o Registered Nurses
o Social Workers
• Random selection of all other professions
• Sample drawn every two years
• Any other profession or board may be audited at
the discretion of HRSA
32
NPDB Guidebook
33
34 34
35
35
Key Changes
What the new Guidebook does:
• Blends Healthcare Integrity and Protection
Data Bank and NPDB to reflect new
combined regulations
• Adds Section 1921
• Provides policy clarification
What the new Guidebook does NOT do:
• Make revisions that require legislative or
regulatory changes
• Accept or address every recommendation
made by commenters.
36
Key Changes
• Eligible entities
o Definition of “Other Health
Care Entity”
o Registration requirements
(use of DBIDs, User IDs)
• Subjects of Reports
o Definitions of health care
practitioners, providers, and
suppliers
37
Key Changes
• Queries
o Centralized credentialing
o Delegated credentialing
o Clinical vs. non-clinical privileges
• Reports
o Submitting reports
- Corrections vs. revisions
- Appeals
38
Key Changes
• Reporting Medical Malpractice Payments
o Oral vs. written claims
o Identifying practitioners
• Reporting Adverse Clinical Privileges
Actions
o Summary Suspensions
o Proctors
39
Key Changes
o Investigations
Definition of term is not controlled by entity’s bylaws.
Routine review of a practitioner is not an investigation.
Focus on a particular practitioner.
Precursor to professional review action.
Ongoing until decision-making authority takes final action.
40
Key Changes
• Reporting Adverse Professional Society
Membership Actions
o Expert witness testimony
• Other adjudicated actions
o Taken in conjunction with clinical
privileges actions
41
Key Changes
• Reporting Licensure and Certification Actions
o Administrative fines
o Summary/Emergency suspensions
o Stayed actions
o Denials
o Withdrawals, and failure to renew while
under investigation
o Voluntary surrenders
42
Resources
Help When You Need It www.npdb.hrsa.gov
•
•
•
•
•
•
•
•
•
FAQs, Brochures, and Fact Sheets
NPDB Guidebook
Recorded Webinars
Instructions for Reporting and Querying
Regulations
Statistical Data
Research Tools
NPDB newsletter
NPDB Customer Service Center
• 800-767-6732
NPDB Compliance Tip Line
• Email help@npdb.hrsa.gov
301-945-9601
43
Questions
44
Contact Information
Margarita Morales, MS
Division of Practitioner Data Bank
Bureau of Health Workforce
Health Resources and Services Administration
U.S. Department of Health and Human Services
Telephone: 301-443-2300
Email: mmorales@hrsa.gov
45
Q & A Game
46
Subjects of Reports
Question 1:
• If a State board that regulates NPs issues a
cease and desist order against a person who is
not a NP but who is practicing as one, is the
issuance of the cease and desist order
reportable to the NPDB?
47
Subjects of Reports
Answer 1:
Yes. In this example, the State regulates the practice of
NPs and prohibits individuals from practicing as NPs –
even if they do not refer to themselves as NPs – without
being licensed by the board. NPDB regulations require the
reporting not only of individuals who are licensed, but also
those who hold themselves out to be so licensed.
Therefore, the cease and desist order issued by the board
would be reportable.
48
Subjects of Reports
Question 2:
• Mercury Hospital’s peer review panel restricts a
nurse practitioner’s clinical privileges for 30 days
due to concerns about his ability to perform
certain procedures safely. Is this reportable?
49
Subjects of Reports
Answer 2:
It depends. Clinical privilege actions/panel
membership actions taken against a practitioner
other than a physician or dentist may be reported.
However, to be reportable, the action must
adversely affect the practitioner’s clinical privileges
for more than 30 days.
50
Queries
Hospital’s Querying Requirement
Question 3:
• Under what conditions are hospitals required to
query every 2 years on courtesy staff who are
afforded only non-clinical professional
privileges?
51
Queries
Hospital’s Querying Requirement
Answer 3:
Hospitals are required to query on courtesy staff
considered part of the medical staff, even if
afforded only non-clinical professional courtesies
such as use of the medical library and continuing
education facilities. If a hospital extends nonclinical practice courtesies without first appointing
practitioners to a medical staff category, querying
is not required on those practitioners.
52
Queries
Hospital’s Querying Requirement
Question 4:
• An advanced practice nurse (APRN) is applying
for a position at a hospital. Does the hospital
have to query the NPDB on the nurse?
53
Queries
Hospital’s Querying Requirement
Answer 4:
It depends. If the hospital considers the position the APRN
is applying for to be on the hospital’s medical staff, or if the
APRN will hold clinical privileges at the hospital, the
hospital must query on the APRN when the APRN applies
and biennially thereafter while the APRN is on staff or holds
privileges. If the hospital does not consider the position to
be on the medical staff or if the APRN will not hold clinical
privileges, the hospital is not required to query on the
APRN. It may do so if it desires, however.
54
Reports
Submitting Reports: Correction vs. Revision
Question 5:
• If an entity changes the penalty it imposes or
reconsiders the grounds upon which it took an
action, should a correction or revision be filed?
55
Reports
Submitting Reports: Correction vs. Revision
Answer 5:
If an entity subsequently changed the penalty it
imposed, or if it reconsidered the grounds on
which it took an action, but the original report
correctly described the penalty or grounds at the
time the original report was filed, then a Revisionto-Action Report, not a Correction Report, should
be filed.
56
Reports
Medical Malpractice Payments
Question 6:
• Following an unsuccessful course of treatment, a
patient and a practitioner enter into a Statesponsored voluntary series of discussions in an
attempt to settle their disagreement before resorting
to litigation. The discussions lead to the
practitioner’s insurance company making a money
payment to the patient to settle the dispute. Should
this money payment be reported to the NPDB?
57
Reports
Medical Malpractice Payments
Answer 6:
It depends. If, during the course of discussions, the
patient made a written complaint or written claim
demanding a monetary payment for damages, the
payment must be reported. If the complaint or
claim for damages was never put in writing, the
payment is not reportable.
58
Reports
Medical Malpractice Payments
Question 7:
• If an individual practitioner is not named,
identified, or described in a medical malpractice
claim or complaint, but the facility or practitioner
group is named, should the payment be
reported?
59
Reports
Medical Malpractice Payments
Answer 7:
No, with one exception. If the named defendant is
a sole practitioner identified as a “professional
corporation,” a payment made for the professional
corporation must be reported for the practitioner.
60
Reports
Clinical Privileges Actions
Question 8:
• Based on assessment of professional
competence, a proctor is assigned to watch a
NPs procedures for a period of more than 30
days, and the proctor needs to be present or
grant approval before medical care is provided
by the practitioner. Is this reportable to the
NPDB?
61
Reports
Clinical Privileges Actions
Answer 8:
It depends. Clinical privilege actions/panel
membership actions taken against a practitioner
other than a physician or dentist may be reported.
However, to be reportable, the action must
adversely affect the practitioner’s clinical privileges
for more than 30 days
62
Reports
Clinical Privileges Actions
Question 9:
• A NP who applied for clinical privileges does not
meet a health plan’s threshold criteria for the
privileges and withdraws the application. Is this
reportable to the NPDB?
63
Reports
Clinical Privileges Actions
Answer 9:
No. A health plan should not report the withdrawal
of a NPs application for clinical privileges when the
NP fails to meet the health plan’s threshold
requirements.
64
Reports
Clinical Privileges Actions
Question 10:
• A NP applied for a medical staff appointment at
a hospital but then withdrew the application
before a final decision was made by the
hospital’s governing body. The NP was not
being specifically investigated by the hospital.
Should the withdrawal of the application be
reported to the NPDB?
65
Reports
Clinical Privileges Actions
Answer 10:
No. Absent a particular investigation, the voluntary
withdrawal of an application for medical staff
appointment or clinical privileges should not be
reported to the NPDB.
66
Reports
Clinical Privileges Actions
Question 11:
• A physician applied to a hospital for clinical privileges to
perform cardiac procedures. The hospital requires that
such applications be granted only if the applying
physician has performed 50 cardiac procedures in the
previous year. The applying physician has performed
only 40 such procedures. The hospital denies the
application based solely on the physician not having met
its 50-procedure requirement. Should this denial be
reported to the NPDB?
67
Reports
Clinical Privileges Actions
Answer 11:
No. A denial of clinical privileges that occurs solely
because a practitioner does not meet a health care
institution’s established threshold criteria for that
particular privilege should not be reported to the
NPDB. Such denials are not considered to be the
result of a professional review action relating to the
practitioner’s professional competence or professional
conduct but, rather, are considered to be decisions
based on eligibility that are not reportable.
68
Reports
Clinical Privileges Actions
Question 12:
• When a NP surrenders medical staff privileges
due to personal reasons, infirmity, or retirement,
and such a surrender did not occur in order to
avoid an investigation or during an investigation,
should it be reported to the NPDB?
69
Reports
Clinical Privileges Actions
Answer 12:
No. The surrender not should not be reported to the NPDB
because the NP did not surrender her clinical privileges while
under investigation by a health care entity relating to possible
professional incompetence or improper professional conduct,
or in return for not conducting such an investigation. However,
if an investigation was under way when the NP surrendered
her privileges, even if the NP was not aware of the
investigation, the surrender would have to be reported even if
the NP claimed she surrendered the privileges for unrelated
personal reasons.
70
Reports
Clinical Privileges Actions
Question 13:
• A health plan terminated a NPs contract for
causes relating to poor patient care, which in
turn resulted in the loss of the practitioner’s
network participation. Should this be reported to
the NPDB using one or two reports?
71
Reports
Clinical Privileges Actions
Answer 13:
Depending on the circumstances, the health care
entity may be required to submit two different
reports. The loss of the practitioner’s network
participation that resulted from the termination of
the contract for reasons relating to professional
competence or professional conduct must be
reported as a clinical privileges action only if it is
considered to be a professional review action by
the health care entity.
72
Reports
Clinical Privileges Actions
Question 14:
• A preferred provider organization (PPO)
investigated a member NP after receiving quality
of care complaints from several plan
participants. The NP was unaware of the
investigation, but, during the investigation, he
relinquished his panel membership for personal
reasons. Is this reportable?
73
Reports
Clinical Privileges Actions
Answer 14:
Yes. A health care entity must report a NPs surrender of
panel membership (a form of clinical privileges) while under
investigation. The reporting entity should be able to
produce evidence that an investigation was initiated prior to
the surrender, and the NPs awareness of the investigation
is immaterial. In addition, in this situation, any termination
of the NPs contract with the PPO must be reported to the
NPDB separately if the action meets the definition of an
“other adjudicated action or decision.”
74