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Federal Hospitals
If you are a federal hospital or federal government agency administering health care services, you may have additional reporting requirements besides reporting adjudicated actions, exclusions, civil judgments and civil convictions. They may include submitting reports under an MOU on clinical privileges actions and medical malpractice payments to the NPDB.
Memorandums of Understanding and Federal Hospitals
The U.S. Department of Health and Human Services has entered into Memorandums of Understanding (MOU) with the following federal agencies to ensure their participation in the NPDB system.
- DOD
- VA
For these agencies, the reporting procedures and requirements for reporting clinical privileges and medical malpractice payments are governed by a Memorandum of Understanding (MOU) as well as by their agency specific policies and procedures.
Attestation
Attestation is our national education and outreach effort to ensure that all eligible entities are meeting their reporting and querying requirements. During attestation, Data Bank administrators attest that their organization has submitted all reportable actions to the NPDB and queried as required by law.
Every 2 years federal hospitals will update their profiles and complete attestation during the registration renewal process. Attestation confirms that federal hospitals have submitted all required reports over the previous 2-year time frame.
Federal hospitals are notified by email when it is time to renew their registrations, update their profiles, and complete attestation. The NPDB sends a 60-day reminder email to the Data Bank administrator prior to the organization's registration and attestation due date. If your federal hospital does not receive a notification, then your renewal is not currently due. If your federal hospital is asked to attest, detailed instructions for attestation are available when you sign in to your account to renew.
To find your specific registration renewal date, complete the following steps:
- Sign in to the NPDB.
- The renewal date is displayed on the lower left hand side of the Entity Registration Confirmation page.
All information submitted to the NPDB is considered confidential. This information may not be disclosed except as specified in the NPDB statutes and regulations. The confidential receipt, storage, and disclosure of information are essential to NPDB operations.
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Clinical Privileges Actions
Federal hospitals or federal government agencies administering health care services must report to the NPDB certain actions taken against health care practitioners, entities, providers, or suppliers as governed by Memorandums of Understanding or by their agency specific policies and procedures.
Medical Malpractice Payments
Federal hospitals or federal government agencies administering health care services must report to the NPDB medical malpractice payments made for the benefit of health care practitioners as governed by Memorandums of Understanding or by their agency specific policies and procedures.
Each hospital must request information from the NPDB as follows:
- When a physician, dentist, or other health care practitioner applies for medical staff appointment (courtesy or otherwise) or for clinical privileges at the hospital, including temporary privileges.
- Every 2 years on all physicians, dentists, and other health care practitioners who are on its medical staff (courtesy or otherwise), or who hold clinical privileges at the hospital.
The confidentiality provisions of Title IV, Section 1921, and Section 1128E allow an eligible entity receiving information from the NPDB to disclose the information to others who are part of an investigation or peer review process, as long as the information is used for the purpose for which it was provided. In those instances, everyone involved in the investigation or peer review process is subject to the confidentiality provisions of the NPDB.
Quick Links
All hospitals with a formal peer review process should be registered with the NPDB. Even if your hospital uses an agent or Credentials Verification Organization (CVO) to query the NPDB, your hospital must first register with the NPDB. After the registration process is complete, you may designate the agent or CVO to act on behalf of your organization.
Note: If your hospital is not owned and operated by a government agency, you should select "Private Sector Organization" on the Organization Information page, even if your organization receives federal or state funds.
Once your hospital is registered, each individual using the NPDB must have a unique user ID assigned by their administrator in the NPDB system. Users cannot share user IDs and/or passwords.
Quick Links
- May I share my hospital's query response?
- How do I submit a report?
- How do I modify a report?
- Are healthcare organizations at the risk of lawsuits when a report is made to NPDB?
- What is considered an investigation for NPDB reporting purposes?
- If a physician's initial application for clinical privileges is denied or the privileges granted are more limited than those requested, must this be reported to the NPDB?
- Is proctoring reportable to the NPDB?
NPDB Guidebook Q&As
- Under what conditions are hospitals required to query every 2 years on courtesy staff members?
- Are hospitals required to query the NPDB on medical and dental interns and residents?
- Are hospitals required to document and maintain records of their requests for information?
- If a health care entity cannot find or did not receive a response to a query, may the health care entity request a copy from the NPDB?
- A hospital would like to enroll its medical staff in Continuous Query. Will the hospital still have to submit One-Time Queries when the hospital's mandated 2-year review is due?
- May self-queries be used to satisfy a hospital's mandatory query requirements?
- A hospital is in bankruptcy. Is it still required to query the NPDB?
- During a hospital's credentialing process, an NPDB query is included in the materials presented to the credentialing committee for peer review. A health care practitioner appeals a decision made by the credentialing committee, and the appeal goes to a separate review body that was not involved in the original decision. Is providing the NPDB query result to the appeal body a violation of NPDB confidentiality rules?
- May hospitals query on health care practitioners who they do not credential or privilege but who they hire, such as nurses?
- A hospital recently queried the NPDB on a physician who was subsequently granted privileges. If the hospital obtains written consent from the physician, may the hospital share the NPDB query results with another health care entity that is not part of the hospital's investigation or peer review process but is registered with the NPDB?
- An advanced practice nurse (APRN) is applying for a position at a hospital. Does the hospital have to query the NPDB on the nurse?
