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Attestation Teleconference

The Attestation Teleconference was held on November 18, 2020.

Event Materials: Attestation Teleconference presentation (PDF - 1.6 MB).

Q&As

  1. What is attestation?
    Attestation is our national education and outreach effort to ensure that all eligible organizations are meeting their NPDB reporting, querying, and confidentiality requirements. During attestation, every 2 years organizations confirm that they have submitted all reportable actions and medical malpractice payments to the NPDB. Hospitals also confirm that they have completed all querying requirements as required by the federal law. Organizations will be notified in their registration renewal emails whether their attestation is scheduled to occur during the current renewal cycle.

  2. Why is attestation necessary?
    Attestation is an education and outreach effort:
    • To help organizations understand their NPDB reporting, querying, and confidentiality obligations, and
    • To ensure that all eligible organizations are meeting their NPDB reporting, querying, and confidentiality requirements. During attestation, organizations confirm that they have submitted all required reports on adverse actions taken and medical malpractice payments made.

  3. What value does the attestation process give the NPDB?
    The attestation process ensures organizations understand their reporting, querying, and confidentiality obligations. Your reporting adds valuable information to guide organizations as they make hiring and credentialing decisions.

  4. How often do account holders need to attest to information about their NPDB accounts?
    Registered organizations update and review their NPDB registration information and complete attestation every 2 years.
    Please do not wait for attestation to submit a report. Under federal law, reports must be filed within 30 days of when a reportable action is taken or a medical malpractice payment is made. However, if a report is filed outside that time frame, we will accept the report. In fact, federal law requires that late reports be submitted.
    Note: Your organization must be registered for at least 2 years before you are asked to attest.

  5. What happens if I don't attest?
    If your organization doesn't attest, you are flagged in our system as having failed to complete your attestation. The most common reason for not attesting is that an organization didn't renew its registration.

  6. What happens if I attest "no"?
    When you are completing your registration renewal, if you attest "no," the system will prompt you to enter a reason.
    The most common reason for a "no" attestation is that the organization didn't have any reports to submit. If your organization did not have any reports to submit, the attestation response should be "yes": you have submitted all reportable actions and medical malpractice payments to the NPDB.
    When we receive a "no" response we will follow up with you by email, provide you with additional information, and answer any questions that you may have. One legitimate reason for not attesting that you have met all NPDB reporting, querying, and confidentiality requirements is that pending reports are in legal review.

  7. I am not certain if we need to attest. We have not had any reportable incidents or made any medical malpractice payments. Under those circumstances, do we need to attest?
    All organizations complete attestation as part of their NPDB registration renewal. If you have had nothing to report for the 24-month period between renewals, we encourage you to still complete attestation. Having nothing to report does not mean you should tell us that you do not attest.
    As far as medical malpractice payments, there are specific reporting requirements. The medical malpractice payer landing page is a good place to start for additional information. You also can take a look at the Guide to Reporting Medical Malpractice Payments infographic.

  8. I use an agent for querying and reporting to the NPDB. How does this affect my organization's attestation?
    It is your organization's responsibility to attest, whether or not you use an agent. If you discover that the agent has not submitted all required reports to the NPDB, it is your organization's responsibility to make sure that those reports are submitted before the attestation process can be completed. The same is true for hospitals with respect to their querying obligations; federal law requires hospitals to query the NPDB under specific circumstances.

  9. When do I attest? Are entities notified when they need to attest?
    You attest when you renew your registration every 2 years.
    The NPDB will send reminder email messages prior to the organization's NPDB registration renewal and attestation due date. Administrators are notified 60 days before the due date. If the renewal is not completed, all account holders are reminded again 30 days, and then again5 days, before the due date.
    If your organization has not received a notification, then your renewal and attestation are not currently due. To find your renewal date, sign into the secure NPDB website; the renewal date will appear on the Entity Registration Confirmation page.
    You must be registered for at least 2 years before you will be asked to attest.

  10. What are the requirements for attestation?
    You will see the specific requirements in the secure NPDB system as you move through each screen when you access registration renewal:
    • The person who attests must be an account administrator and must be able to confirm your organization's compliance with reporting, querying, and confidentiality requirements
    • You must be able to confirm:
      • You have access to all potentially reportable actions or payments made by your organization
      • All required reports were submitted for the 24-month period
      • Query responses were used in accordance with all NPDB confidentiality requirements
    • If you are not authorized to attest, you must identify and advise the person who is authorized of his or her responsibilities
    • If that person has an administrator account, he or she should sign in and submit the attestation. If they can't do that, with their permission, you can submit the attestation on their behalf

  11. Who is responsible for attesting and reporting within an organization?
    Each eligible organization must identify at least one designated account administrator. The account administrator is responsible for completing the attestation process.
    Reports can be submitted by the account administrator or any other authorized NPDB user within the organization. Also, some organizations use agents to submit reports on their behalf. Note that if you discover that an agent has not reported all the required reports to the NPDB, it is your organization's responsibility to make sure that those reports are submitted.

  12. If only account administrators can complete attestation, how do we add administrator privileges to a user's account?
    It's easy and a good idea to designate a second account holder with administrator privileges.
  13. How do I compare my organization's reporting records with what has actually been submitted to the NPDB?
    When you complete your attestation at the time of your registration renewal:
    • We provide you with information about your volume of NPDB reporting over the 24-month period preceding your renewal and attestation
    • The person who attests must be able to confirm your organization's compliance with all reporting, querying, and confidentiality requirements
    • If you are aware that reports are missing, submit the reports as soon as possible

  14. After I submitted my attestation, I identified additional actions that need to be reported. What should I do?
    Submit the reportable actions and then edit the attestation form, attesting that you have submitted all required reports.

  15. Can a state licensing and certification agency complete attestation if the agency is listed as non-compliant?
    A state licensing board should complete attestation when it renews its registration. If the board is non-compliant because it failed to submit all reportable actions, the board should report the missing actions as soon as possible. The attestation response submitted should reflect whether the board submitted all actions to the NPDB for the period under review, as required by law.

  16. What are the results of attestation so far?
    To date, thousands of organizations have successfully completed attestation, resulting in a very high completion rate.

  17. Where can I find more about attestation?
    On the NPDB website home page, in the left hand column labeled "For Organizations," click on Your Organization and then select the type of organization you represent. Once you are on the appropriate landing page, either read directly about attestation or click on the "Attestation" link for more information.

  18. We're supposed to attest that we've submitted all reports required by federal law. How do I find out more about what we're required to report?
    Different types of organizations have different reporting requirements. Start by clicking Your Organization under "For Organizations" in the left hand column of the NPDB home page. Then choose the type of organization you're interested in. Either in the text on the resulting page or through a link near the bottom of that page, you'll find information about what to report.
    You can also use the search box on the top right of the NPDB home page to find additional information.
    The NPDB Guidebook has a chapter on reporting, broken down by type of action reported, and complete with Q&As, infographics, and many examples.

  19. What type of actions must be reported to the NPDB?
    NPDB regulations require eligible entities to report the following:
    • Medical malpractice judgments and settlements
    • Adverse licensing and certification actions
    • Clinical privileges actions
    • Health plan contract terminations
    • Professional society membership actions
    • Negative actions or findings of private accreditation and peer review organizations
    • Government administrative actions, e.g. exclusions from programs
    • Civil and criminal health care-related judgments

  20. Are we required to report on allied health professionals or only physicians and dentists?
    Hospitals and other health care entities must report adverse clinical privileges actions against physicians and dentists that meet NPDB reporting criteria. Hospitals and other health care entities are encouraged to report clinical privileges actions taken against health care practitioners other than physicians and dentists when those clinical privileges actions are based on the practitioner's professional competence or professional conduct that adversely affects, or could adversely affect, the health or welfare of a patient.
    For more information, see the NPDB Guidebook section on Reporting Adverse Clinical Privileges Actions.

  21. Are residencies required to report on residents who have been put on probation or when similar, otherwise reportable, actions are taken?
    Residents and interns generally should not be the subjects of adverse clinical privileges actions because they are trainees in graduate health profession education programs and are not granted clinical privileges within the meaning of NPDB regulations, but they are authorized by the sponsoring institution to perform clinical duties and responsibilities within the context of their graduate education program. However, adverse clinical privileges actions based on events occurring outside the scope of a formal graduate educational program-for example moonlighting in the intensive care unit or emergency room-must be reported.

  22. How do I find out more about what queries we can submit, so that I can attest?
    Hospitals are the only type of organization required by federal law to query, but almost all other types of organizations are encouraged to query under certain circumstances. Querying the NPDB helps health care organizations fulfill a mission they share with the NPDB-improving the quality of health care and providing protection from unfit health care practitioners.
    To find out more, start by clicking Your Organization under "For Organizations" in the left hand column of the NPDB home page. Then choose the type of organization you're interested in. Either in the text on the resulting page or through a link near the bottom of that page, you'll find information about when to query.
    You can also use the search box on the top right of the NPDB home page to find additional information.
    And don't forget the NPDB Guidebook, which has a chapter on querying, complete with Q&As.

  23. Should a hospital query on retired medical staff that remain members without privileges?
    Yes, if the retired individuals remain members of the medical staff. Each hospital must request information from the NPDB 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, and 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.

  24. What about information on confidentiality? We're asked to attest that we've followed all confidentiality requirements.
    Information reported to the NPDB is considered confidential and may not be disclosed except as permitted by law. The confidentiality provisions of the law allow an eligible entity receiving information from the NPDB to disclose that information to others who are part of the same 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 NPDB.

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