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NPDB-HIPDB News

January 2012 Newsletter


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Enhancements Simplify Multiple Data Bank Processes

On January 23, 2012, the Data Bank will introduce a number of enhancements aimed at streamlining processes for many Data Bank reporters and queriers, including State Licensing and Certification Agencies and Data Bank Administrators who are responsible for registering their organizations. The changes, summarized below, have the potential to benefit a large segment of the Data Bank community.

Report Forwarding to State Boards

One of the main new features coming to the Data Bank in January will eliminate the need for reporters to mail a copy of Data Bank reports to their relevant State Licensing Board. Reporters of Medical Malpractice Payments, Clinical Privilege, and Professional Society actions must print and mail a copy of the report to the appropriate State agency. Now, the Data Bank will make it easier for reporting organizations to comply with this requirement by enabling them to transmit reports electronically to State Licensing Boards that opt to participate in the new feature.

The automatic report forwarding option requires dual authorization-first by State Boards that must elect to participate, and subsequently by reporters at the time they submit each report. Electronic forwarding will not occur unless both sides agree to the exchange. To take advantage of this feature, each State Board that opts for report forwarding will verify the health care practitioner types they license or certify and agree to receive the reports electronically. Refer to the new State Board Profile page in Figure 1. Reporting organizations will choose to electronically forward their reports to the relevant agency on a report-by-report basis. Electronic report forwarding facilitates compliance with the law, and reporters who take advantage of it no longer need to remember to print and mail paper reports to State Boards.

In cases where a State Board declines to participate, or if a reporting organization prefers not to use the new feature for submitting a report, reporters remain responsible for sending a copy of the Report Verification Document to the appropriate State Board. The new service will be available initially through the Integrated Querying and Reporting System (IQRS). All State Boards will have a new State Board Profile button on the Administrator Options page, where they may enroll in the service, withdraw their agreement to participate, or modify their profile at any time.

Figure 1
Figure 1: State Boards must select the practitioner categories they license or certify when they first set up their profiles. This measure is designed to prevent inadvertent disclosures to the wrong licensing agency.

After a report is forwarded electronically, both the reporter and the Board will receive a Notice of Action via email and Data Bank correspondence, notifying them that a report was filed. Another email will notify the reporter when the report is viewed, or if a State Board fails to view a report within 7 days. Figure 2 depicts in more detail how the report forwarding process works. Several mechanisms will help track activity among electronically forwarded reports: The Historical Report Selection page may be used to find reports that have been electronically transmitted to State Boards; and the monthly Data Bank summary email for both reporters and State Boards will include information about the number of reports forwarded electronically and whether the reports were viewed. Use of this convenient report forwarding feature will require less manual work and enable the sending and receiving of required reports more quickly.

Figure 2
Figure 2. State Boards and reporting organizations may elect to use the new report forwarding feature. The process is outlined above.

Registration Enhancements

Another important enhancement taking place in January is a more intuitive entity registration process. This enhancement will simplify an entity's determination of its statutory authority by having the entity answer a few straightforward questions about its organization. As organizations re-register, they also will be able to select additional primary functions to more accurately describe their organizations.

Professional School Report Fields

The professional school report field will be expanded to include schools for chiropractors as well as the existing physician occupations.

Eliminate Mailing of Paper Reports

The Data Bank will begin transitioning toward more reliance on online report change notices instead of sending paper copies by mail. Since 2008, organizations have received report change notices via paper as well as electronically. Most organizations view these notices electronically but have not explicitly opted out of the paper copy, so the January enhancement will complete the transition to on-line report viewing. Organizations that have never reviewed a report change notice online will be given instructions on how to do so and over time they, too, will transition to electronic viewing. Report subjects who currently receive a paper Subject Notification Document will receive instructions on how to view the report online through the Report Response Service. This will not only help protect personally identifiable information by reducing the amount of sensitive information that is sent by mail service, but it also will reduce the amount of paper we print by about 50 percent. Be sure to take advantage of these new features as they become available on January 23rd.

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Health Care Reform Law Will Streamline Data Bank Operations

Last year's health care reform law, the Patient Protection and Affordable Care Act of 2010, included a provision to streamline Data Bank operations. Section 6403 of the Affordable Care Act was designed to eliminate duplicative data reporting and access requirements between the National Practitioner Data Bank (NPDB) and the Healthcare Integrity and Protection Data Bank (HIPDB). The statute requires the Secretary of the U.S. Department of Health and Human Services (HHS) to establish a transition period to transfer all data in the HIPDB to the NPDB and, once completed, to cease HIPDB operations. Information previously collected and disclosed through the HIPDB will then be collected and disclosed through the NPDB. The statute's intent is to transition HIPDB operations to the NPDB while maintaining reporting and querying requirements. HHS is drafting a Notice of Proposed Rulemaking to implement Section 6403 and anticipates its publication in the Federal Register in the near future.

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Security in Review: Exercising Vigilance

Security is a continuous, high-priority activity at the Data Bank, and in recent years we have implemented an exceptional number and variety of improvements.  Some security enhancements were highly visible to Data Bank users, while others may not have been generally obvious. Recent initiatives have included encrypting personally identifiable information, masking data, strengthening password protocols, requiring challenge questions, introducing secure messaging, and changing the way entities and users register with the Data Bank by implementing e-authentication.

There are numerous categories of security threats that all information systems must address to safeguard their information assets. In today's technological environment, the Data Bank is susceptible to a variety of threats, including:

  • Identity threats leading to fraudulent access.
  • Risk of data corruption.
  • Improper data disclosure.
  • Physical storage safety.

As technology evolves, the risks to information systems become more sophisticated and more numerous. Data Bank security initiatives reflect an ongoing commitment to confront these challenges promptly and thoroughly by following security standards and guidelines prescribed by the National Institute of Standards and Technology (NIST). For the Federal Government especially, adherence to NIST standards is compulsory and provides the foundation for an effective security policy.

NIST may issue any number of recommendations in a given year. As each new standard is published, the Data Bank must determine how best to incorporate these requirements into the framework of its system architecture, while taking into account its own requirements for meeting the needs of Data Bank users. The ongoing reassessment of security is a process that entails a great deal of planning and preparation, and often the renegotiation of priorities. In essence, security is a constant balancing act between risk and usability, with the ultimate goal of ensuring the safety of Data Bank information.

As we begin a new year, the Data Bank urges its users to review their work areas where threats may exist, from safeguarding physical assets at workplaces to restricting access where and when it is needed. As technology advances, the need for security will remain a challenge that requires continuing vigilance. Safe practices result in secure data, and the entire Data Bank community plays an important role in bringing that about.

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Reporting Responsibilities for Health Plans

Health plans exercise an enormous influence on the delivery of health care in the United States. By reporting to the Data Bank, health plans help to protect patients from incompetent practitioners and to stop fraudulent health care practices. The Healthcare Integrity and Protection Data Bank (HIPDB) defines a "health plan" as a plan, program, or organization that provides health benefits, whether directly through insurance, through reimbursement, or otherwise. Examples of health plans include health maintenance organizations, third party administrators, and health insurance companies.

Health plans are required to report to the HIPDB and, in some cases, the National Practitioner Data Bank (NPDB). This article provides a brief overview of the dual eligibility requirements for health plans and their associated reporting responsibilities.

HIPDB Reporting Requirements

HIPDB regulations specify two types of final adverse actions that health plans must report: health care-related civil judgments and "other adjudicated actions or decisions." These actions must be reported to the Data Bank within 30 days of the action being taken. Table 1 describes each HIPDB reporting requirement, identifies the type of Data Bank report that a health plan would use to submit information about an action, and provides examples of reportable actions.

NPDB Reporting Requirements

The NPDB definition of a "health care entity" includes organizations that provide health care services and have a formal peer review process to further quality health care. The phrase "provides health care services" means the delivery of health care services through any of a broad array of coverage arrangements or other relationships with practitioners, either by employing them directly or through contractual or other arrangements. The definition, therefore, may include a range of managed care organizations or other types of health plans.

Health care entities are required to report adverse clinical privileges and panel membership actions to the NPDB within 30 days of the action being taken. Table 2 lists the specific NPDB reporting requirements for health plans that are "Health Care Entities." In addition, any entity, including a health plan that makes medical malpractice payments for the benefit of a health care practitioner, must report those payments to the NPDB.

Your Role is Important

Health plans play an important role in combating fraud and protecting the public, so it is important to be familiar with the Data Bank reporting requirements. To aid you in your reporting, there are ample resources on the Data Bank Web site, including the Data Bank Guidebooks (http://www.npdb-hipdb.hrsa.gov/guidebooks) and the new reporting flow charts that clarify these and other Data Bank reporting requirements (http://www.npdb-hipdb.hrsa.gov/referencelibrary). Data Bank customer service representatives are always happy to assist you with any questions you may have.

Table 1. HIPDB Reporting Requirements for Health Plans

Reporting Requirement HIPDB Report Type Example
Health Care-Related Civil Judgments
  • includes civil judgments against health care practitioners, providers, or suppliers related to the delivery of a health care item or service.
Civil Judgment

A health plan sues a physician group practice over allegations of fraudulent billing. The court renders a judgment in favor of health plan and awards the plan $300,000 in damages.

Other Adjudicated Actions or Decisions that:
    • are formal or official final actions taken against a health care practitioner, provider or supplier.
    • are based on acts or omissions that affect or could affect the payment, provision or delivery of a health care item or service, and
    • include the availability of a due process mechanism

    Examples include contract terminations and personnel actions. This definition excludes clinical privileges actions or health plan paneling decisions.*

    *A clinical privileges/panel membership actions taken in conjunction with an "other adjudicated action or decision," such as a contract termination, must be reported separately.

Health Plan Action

A preferred provider organization formally terminates its contract with a physician about whom it has received quality of care complaints. The physician was provided an opportunity for a hearing to discuss the allegations. The practitioner declines the hearing. The organization formally terminates the physicians contract.

A managed care organization decides not to renew a psychologist's contract based on concerns over professional competence. The practitioner received a formal hearing before the decision became final.



Table 2. NPDB Reporting Requirements for Health Plans that are "Health Care Entities"

Reporting Requirement NPDB Report Type Example

Clinical Privileges or
Panel Membership Actions that:

  • are professional review actions taken against physicians and dentists,
  • adversely affect clinical privileges/panel membership for more than 30 days.
  • include voluntary surrenders or restrictions of privileges or membership while under or to avoid investigation.

Clinical Privileges/ Panel Membership

The peer review committee that makes all network membership decisions for a preferred provider organization takes a professional review action and permanently removes a physician from the network based on substantiated concerns about her professional competence.

Note: Any termination of the physician's network contract in this case that meets the definition of an "other adjudicated action or decision" must be separately reported to the Data Bank as a Health Plan Action.

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Data Bank Outreach and Education Activities

We frequently update our outreach activities schedule so please also refer to our Web site.

Recent Outreach Activities

Conference Location Date
Data Bank Agent and Composite Board Education Forum St. Louis, MO October 20, 2011
NPDB Executive Committee Meeting Arlington, VA November 3, 2011
Oklahoma Association Medical Staff Services (OKAMSS) Annual Meeting Oklahoma City, OK December 1, 2011

Upcoming Outreach Activities

Conference Location Date Role

National Credentialing Forum (NCF) 2012 American Osteopathic Information Association

San Diego, CA February 3–4, 2012 Speaking

American Health Lawyers Association (AHLA) Physicians and Physician Organizations Law Institute

Orlando, FL   February 8–9, 2012 Speaking

Health Care Compliance Association (HCCA) Managed Care Compliance Conference

Scottsdale, AZ February 12–14, 2012 Exhibiting

America’s Health Insurance Plans (AHIP) 2012 National Policy Forum

Washington, DC March 6–7, 2012 Exhibiting

California Association of Medical Staff Services (CAMSS) San Diego & Orange County Chapters 2012 Joint Education Conference

Orange County, CA March 22–24, 2012 Speaking

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Helpful Hints from the Data Bank

Reporting Medical Malpractice Payment Reports (MMPRs) - The National Practitioner Data Bank (NPDB) Guidebook states that an entity that makes a payment for the benefit of a physician, dentist, or other health care practitioner in settlement of, or in satisfaction in whole or in part of, a claim or judgment against that practitioner must report the payment information to the NPDB. Payments made on behalf of deceased practitioners, or for the benefit of their estate, also must be reported to the NPDB. A payment made as a result of a lawsuit or claim solely against an entity (for example, a hospital, clinic, or group practice) that does not identify an individual practitioner is not reportable under the NPDB's current regulations.

Reports must be submitted to the NPDB and the appropriate State Licensing Boards within 30 days of the date that a payment is made (the date of the payment check). The report must be submitted regardless of how the matter was settled (for instance, court judgment, out-of-court settlement, or arbitration). Additional information about MMPRs is available in the NPDB Guidebook, Chapter E, pages 8-16.

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A CVO Supervisor Shares Her Continuous Query Experience

Genni, who serves as the Supervisor of CVO Operations, has been using Continuous Query for over 4 years. She talks to the Data Bank about her experiences using Continuous Query.

Background

  • Point of Contact: Genni, CPCS, CPMSM, Supervisor CVO Operations
  • Region: Midwest.
  • Using Continuous Query since August 2007.
  • CVO (agent for eight hospitals; a Children Hospital; Rehabilitation Institute; Behavioral Health and Medical Group.)
  • 5,000 private practice physicians.
  • Recredentialing between 2,000 to 2,500 practitioners per year.
  • Approximately 350-550 practitioners re-credentialed every other month.

"When I first heard about the Data Bank's Continuous Query back in May 2007, I thought it was a great idea and something that the organizations I represent would be interested in using. As the Credentialing Verification Organization (CVO) supervisor, I took the information to the Medical Staff Office meeting and explained the Continuous Query program to the members. Everyone at the meeting was 100 percent on board for participating in the program and agreed that helping to play a role in protecting the public is why we are here."

"We are sent a notification email when a report is received from the Data Bank on an enrolled practitioner, so we can immediately access and follow up on the report. The information is always available to us and the system is easy to use. We were able to get in on the ground floor and have used Continuous Query since 2007. We think it is great!"

"Just one report can make a big difference." - Genni, May 2011

"The Continuous Query service also fits perfectly with the Joint Commission standards that encourage continuous monitoring: Ongoing Professional Practice Evaluations (OPPEs) and Focused Professional Practice Evaluations (FPPEs). By using Continuous Query, you have the information at your fingertips and you can print it immediately. In the long run, Continuous Query is more efficient and hospitals are more aware of reports as they come in. We are not waiting 2 years to know about reportable issues."

"As the CVO for 11 organizations, all of our providers are enrolled in Continuous Query. Upon completing each new practitioner file for approval by the board of directors, we now enroll them in Continuous Query. Originally, we completed a one-time query for $4.75 for each practitioner prior to sending their file to the Board of Directors for approval. Then, upon approval, we enrolled them in Continuous Query. We quickly realized that instead of completing a one-time Data Bank query for $4.75 and enrolling them later, we could enroll practitioners in Continuous Query initially for $3.25 prior to sending the file to the entity for approval, and save $1.50 each time. With more than 1,000 practitioners initially enrolled in Continuous Query, our savings would be significant. In addition, we receive continuous monitoring for 1 year on each enrolled practitioner. We recredential approximately 2,000-2,500 practitioners per year, which is about 350-550 practitioners every other month. All we have to do is print the Continuous Query enrollment and assign the file to an analyst for processing. After the primary verifications are completed, a profile is created and we forward the files to the organization that we represent. The organization will take the files for review and final approval by the Board of Directors. When the Joint Commission comes to perform an audit, the organization has the file on hand. If a practitioner receives a Data Bank report during the year, both the organization and we as the agent are notified by email. The CVO runs the report and files it in the appropriate practitioner file. Each hospital has its own process for reviewing the practitioner report."

"The hospitals we represent are happy with the Continuous Query service. They like knowing about the reports as they occur and not having to wait for the 2-year recredentialing cycle. I really believe this makes a big difference. We are assured that if a practitioner gets a Data Bank report, we will know about it immediately. I definitely recommend it to others. I also am willing to share the processes that we have in place, and I have done so at conferences with other organizations that are thinking about using Continuous Query. The bottom line is protecting the public. Patients will suffer if your organization doesn't know about reports. With Continuous Query everything is at your fingertips whenever you need it."

"In the long run Continuous Query is more efficient. Hospitals are more aware of reports as they come in, and they don't have to wait for the 2-year recredentialing cycle." - Genni, May 2011

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Dear Data Bank

This column answers questions about Data Bank policies and procedures. If you have a question, please email "Dear Data Bank." We look forward to hearing from you!

Question: Do outpatient clinics have querying and reporting responsibilities?
Answer: Yes-if a stand-alone clinic performs professional review activities, it is eligible to query and is required to report professional review actions to the Data Bank.  These adverse actions must be related to a physician’s professional competence and conduct and adversely affect the physician’s clinical privileges for more than 30 days in order to be reportable. 

Question: Can query results, i.e., reports, be shared with entities other than the querying entity?  Can they be shared for the purpose of an audit, for example?
Answer: No, query results are considered confidential and should not be disclosed except as specified in the National Practitioner Data Bank regulations at 45 CFR Part 60.  During an audit, the National Committee for Quality Assurance, Joint Commission, or other auditors may view only the cover page showing that the facility queried the Data Bank. They are not authorized to view the details of the report.

Question: Can you tell me if I need to report the suspension of a hospital resident?
Answer: The suspension of a resident would not be reportable if the action was taken within the scope of his or her training program.  Residents and interns are trainees in graduate health profession education programs, and they are not granted clinical privileges per se, but they are authorized by the sponsoring institution to perform clinical duties and responsibilities within the context of the graduate program. 

However, adverse clinical privilege actions related to practices that occur outside the scope of a formal graduate educational program, such as moonlighting in an emergency department, would be reportable.

Question: Each year I submit queries on my organization’s practitioners, and this is a time consuming process.  I complete a query input form on each practitioner, one at a time.  Is there some way that I can store the practitioner’s information so I don’t have to re-enter it every time I query?
Answer: Yes, the Data Bank system is designed so that you do not have to re-enter practitioner information again. Each organization can create a Subject Database to store their practitioner information for future queries or reports.  When querying or reporting a new practitioner, you will have the option to store that practitioner information in the Subject Database.  Retrieval of the stored information is easy: just select the practitioner name from the Subject Database listing and the query or report input form will be prepopulated for you, saving you countless time.  If you already have practitioner information stored on your computer, you can import that information in ASCII fixed-width or XML format to your Data Bank Subject Database.  Look for an article that deals more fully with the Subject Database in our next newsletter. 

Question: If a Data Bank query response shows no reports, but State information notes a closed malpractice claim with a payment, what should we do?
Answer: First, review the information submitted in the query.  If the information appears to be complete and accurate, please call the Data Bank Customer Service Center or use the Reporting Compliance page found on the Query Response section of the Data Bank Web site to report the discrepancy. 

If you would prefer to discuss a specific issue in person, please call the Customer Service Center at 1-800-767-6732. Information Specialists are available to speak with you weekdays from 8:30 a.m. to 6:00 p.m. (5:30 p.m. on Fridays) Eastern Time. The Customer Service Center is closed on all Federal holidays.

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On the Horizon

Data Bank Newsletter Goes Paperless April 2012

The January 2012 Data Bank News will be the last printed newsletter issue.  In the future, all news will be electronic, and posted to the Data Bank Web site.  You will receive an email when the April 2012 newsletter is available in the PDF and HTML formats.  A complete archive of past newsletter issues will also be maintained on the Data Bank Web site. 

Data Bank statistics show that increasing numbers of readers every month seek out the Data Bank News online.  An electronic newsletter gets the news into your hands faster than the mail does, costs less to produce, conserves trees, and saves time.  We look forward to keeping you informed about important Data Bank news and information electronically.

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