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Health Center Attestation Webinar Q&As

  1. When does my entity have to attest? How do I know when my health center it due for attestation?

    Attestation occurs as part of your entity's NPDB registration renewal process. The registration renewal process occurs every two years. Therefore, in order to determine when your entity will attest, you will need to know when your entity is due to complete its registration renewal.

    To find out the renewal date for your entity, please log into the NPDB system. After you complete the user agreement, the Entity Registration Confirmation page will display your entity's renewal date. Your entity will receive alerts 60, 30, and 5 days prior to the renewal date.

    Note: Your entity must be registered for at least two years before you will need to attest.

  2. When will the attestation option be available for Health Center Program grantees and look-alikes?

    On August 9, 2017, many Health Center Program grantees and look-alikes started receiving registration renewal reminders with the ability to attest. Since Attestation is a part of the NPDB registration renewal process, your entity may not need to attest for a year or two, depending on when your entity is scheduled to renew its registration. Once you finish the registration renewal, you will be prompted to start your attestation.

  3. We are a local government entity, should we select Private Sector Organization as our organization type when going through the registration/attestation process? Our health center is part of a State University, so we are a public entity. What type of organization type should we select?

    If your entity is a part of a local government entity or a part of a state government agency, you should select the appropriate choice, which would be either Local Government Agency or State Government Agency. However, if your health center only receives state and federal funding and is not directly connected with or a part of a state or local government entity, please select Private Sector Organization when you register your entity with the NPDB.

  4. Am I attesting on behalf of my health center or on behalf of my individual providers?

    Attestation is for the NPDB activity of the health center as a whole and the service delivery sites within that health center's scope of project for which it credentials and/or privileges. Therefore, during attestation, you are attesting to the fact that the health center has reported all required clinical privileging actions taken against all physicians and dentists at your health center and those service delivery sites during the previous two-year timeframe.

  5. When does my health center need to complete attestation?

    Your entity should complete Attestation when it renews its NPDB registration. You will get alerts 60, 30, and 5 days prior to the renewal date. If you are unable to complete the attestation at that time, you should complete it as soon as possible after renewal.

  6. Which professions do I have to attest for - MDs, Nurse Practitioners, Nurses, etc.?

    Health Center Program grantees and look-alikes are legally required to report clinical privileges actions taken against physicians (MD/DO) and dentists. Therefore, during attestation, your health center is verifying that it has submitted all legally required reports on physicians and dentists.

    You may report - and 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. We encourage entities to report on other practitioners so that other health centers and employers will have access to important information when making hiring, privileging, and credentialing decisions.

  7. How do we find out if our health center has made any reports to the NPDB if we are new at the center? Is there a way to tell if someone else has previously registered our providers and sites?

    If the health center is a registered user, any reports submitted by the health center will be posted in the NPDB system and can be found by clicking the Reports link. If you are not sure whether your site is registered, contact the NPDB Customer Service Center.

  8. If our health center has not reported any clinical privileges actions in the past two years, how should we respond when we attest?

    If your entity has not taken any clinical privileges actions that are legally required to be reported to the NPDB, you can confirm on the attestation page that your entity has submitted all legally required reports to the NPDB.

  9. If we contract with an outside company to query the NPDB, do we still need to do query the NPDB ourselves? In addition, if we have an outside agency that does our credentialing, do we need to change any of these processes?

    This sounds like an agent relationship, in which the Health Center Program grantee or look-alike uses an outside agency to do its credentialing, including querying and reporting to the NPDB. The relationship should be documented in the Health Center Program grantee or look-alike's Credentialing policies, and the Health Center Program grantee or look-alike must be registered with the NPDB in order to receive the queried information from the agent. The agent should also list the Health Center Program grantee or look-alike as one of the entities it is querying and reporting on behalf of for in the NPDB. The Health Center Program grantee or look-alike is still ultimately responsible for meeting its requirements for querying and reporting, even if they use an agent.

  10. If we are part of a hospital system that reports to the NPDB on our behalf, do we need to set up a separate registration and attestation? Our credentialing is handled by formal delegation to the county hospital we are attached to; as such, we do not access the NPDB directly. Can our health center delegate to an affiliated entity hospital the credentialing and privileging of our providers, and if so, does our health center need to register, query and report?

    If your entity is formally part of the hospital management structure, and your entity has delegated credentialing and privileging functions to the hospital, you do not have to query or report separately. Moreover, in this scenario your entity is not required to attest either.

  11. We have Health Center Program grantee and look-alike sites and non-Health Center Program grantee sites. Do we attest only for the Health Center Program grantee and look-alike providers or all providers?

    You should report on all sites for which you credential and privilege providers, even if some are non-Health Center Program grantee or look-alike sites. If they are sub-recipient sites that are independent and do their own credentialing/privileging, you do not have to report or attest for them.

Policy

  1. Where can I get basic information on what we need to report?

    To learn about reporting to the NPDB, please check out the NPDB Guidebook. Within the Guidebook, there is a specific section about reporting clinical privileges actions, as well as Q&As about reporting clinical privileges actions. Finally, the NPDB website also provides access to the NPDB's legislation and regulations.

  2. If an action has been reported by the provider's licensing board, do we need to report it as well?

    The health center has to report actions that it has taken against a provider's clinical privileges, even if the state licensing board is reporting an action it has taken against the provider's license. They are separate actions and both need to be reported.

  3. If a provider has a reportable action but no longer works for the organization, do you report it?

    If you find that a reportable action was never reported against a provider who no longer works for your health center, you are required to report that action to the NPDB. Besides meeting your legal obligation to report, you are ensuring that other health care entities will have access to the information to inform their hiring and credentialing process.

  4. Should I be running a query on my clinical support staff such as dental assistants and medical assistants? If so, what would the reason for that be?

    Although clinical privileges actions are only required to be reported against physicians and dentist, other health care entities such as health plans, licensure boards, medical malpractice payers, and federal agencies are required to report on all health care practitioners. By querying on other professions, you avail yourself to information in the NPDB that may have been reported by any of these entities.

  5. Do we only report clinical privileges actions we take against the provider regarding his/her credentialing/privileging that are not corrected within 30 days?

    Yes, you may only report clinical privileging actions that last longer than 30 days.

  6. We are beginning a residency program. If the residents are credentialed through a partner entity and it is stated as such in our contract, should we still run them in the query?

    If the residents will be credentialed by the partner entity, and that is reflected in a formal agreement or contract with the health center, the health center does not have to credential the residents separately.

  7. Since we credential and privilege Nurse Practitioners, are we required to attest?

    You will still be asked to attest at the time of your entity's renewal. Because you are only legally required to report clinical privileges against physicians and dentists, you may attest that you are compliant, even if you have reported nothing.

  8. If we have continuous query for NPs, RNs, MAs, etc., does that mean we have to report them too, or are we only required to report on physicians and dentists?

    Reporting is only required for physicians and dentists. However, as an employer you would probably like to know as much information as possible on prospective hires. Therefore, it benefits all other health centers and other health care entities if reports are submitted on these professions as well. Since you are querying the NPDB, you are seeking information that others have reported. When you report, you can help others in the same way.

  9. For Health Center Program grantees or look-alikes that are covered by Federal Torts Claim Act (FTCA), if HHS makes a payment on a claim or enters into a settlement, are Health Center Program grantees or look-alikes required to report the HHS payment to NPDB? If you have an active lawsuit the FTCA is handling, do you need to report it? If we are covered by the FTCA and HHS reports a medical malpractice payment on one of our providers, do we need to report that medical malpractice payment as well on our attestation? What if the HHS Medical Claims Review Panel determines that the practitioner met the standard of care, despite a payment by HHS? Is this reportable to NPDB?

    If you were an FTCA-deemed Health Center Program grantee or look-alike, HHS would be responsible for reporting malpractice payments to the NPDB. However, the Health Center Program grantee or look-alike is still responsible for reporting any clinical privilege-related actions that it has taken, regardless of whether or not a malpractice payment has been made. Your entity's attestation only pertains to those actions your entity is required to report.

  10. Will the NPDB ever list pending cases or require to report pending cases? Sometimes it takes years to see the results of a lawsuit.

    As stated above, HHS is responsible for reporting medical malpractice payments to the NPDB on behalf of FTCA-deemed Health Center Program grantees and look-alikes. HHS will report a medical malpractice payment only after the malpractice case has concluded and a payment has been paid on behalf of the practitioner. Medical malpractice payments are separate from clinical privileges actions. The Health Center Program grantee or look-alike is responsible for submitting reports on clinical privileges actions it takes against providers to the NPDB. Only final actions taken on clinical privileges are reported to the NPDB, with limited exceptions, such as a summary suspension. If you would like to learn more about reporting adverse clinical privileges actions, please refer to the infographic NPDB Guide to Reporting Clinical Privileges Actions or Chapter E: Reports, Reporting Adverse Clinical Privileges Actions of the NPDB Guidebook.

  11. We have contracted providers as well as employed providers, do we attest for both the contracted as well as the employed?

    The Health Center Program grantee or look-alike is responsible for reporting any clinical privileges actions taken against any physician or dentist working at its facility, whether contracted or employed by the health center. Therefore, when you attest, you are attesting that you have reported all legally required clinical privileges actions for all physicians and dentists covered under the NPDB regulations, whether contracted or employed.

  12. What is reportable?
    1. A provider who is behind on charting, who is counseled, and the provider resigns
    2. A provider who is counseled about her competence and resigns.

    The answer to this question hinges on whether the provider surrendered his or her clinical privileges while under investigation when the provider resigned from the health center. The NPDB interprets the word "investigation" expansively. The NPDB does not consider a routine, formal peer review process under which a health care entity evaluates, against clearly defined measures, the privilege-specific competence of all practitioners an investigation for the purposes of reporting to the NPDB. However, if a formal, targeted process is used when issues related to a specific practitioner's professional competence or conduct are identified, this is considered an investigation for the purposes of reporting to the NPDB. In addition, the NPDB considers an investigation to run from the start of an inquiry until a final decision on a clinical privileges action is reached.

    In both scenarios above, if the chart monitoring or counseling is the result of routine and normal practices, then there is no investigation and the resignation is not reportable. Whereas, if the chart monitoring and counseling are the result of a review of a specific provider because of concerns involving the provider's competence or conduct, then it would be considered an investigation and the resignation would be considered a surrender of clinical privileges while under investigation.

  13. If a provider offers to surrender privileges, or surrenders privileges in exchange for not conducting an investigation, is that reportable?

    As stated in the previous answer, a surrender of clinical privileges or failure to renew clinical privileges while under investigation or to avoid investigation must be reported to the NPDB. The reporting entity should be able to produce evidence that an investigation was initiated prior to the surrender of clinical privileges. Examples of acceptable evidence may include minutes or excerpts from committee meetings, orders from officials directing an investigation, or notices to practitioners of an investigation (although there is no requirement that the practitioner be notice or aware of the investigation). Therefore, in this scenario, if a provider surrenders privileges in exchange for not conducting an investigation, that is a reportable action to the NPDB.

  14. Clinical Privileges Action versus an Administrative or Employment Action: If there is a release of contract or no renewal of contract and no "official" investigation - is this reportable? In addition, if we do not renew or end a provider's contract due to concerns related to their clinical skills, do we report that? Where can I find more information about contracts and clinical privileges?

    The question is what constitutes a clinical privileges action and what constitutes an administrative or employment action to determine whether the action is reportable to the NPDB. Adverse clinical privileges actions that must be reported to the NPDB are professional review actions - that is, they are based on a physician's or dentist's professional competence or professional conduct that adversely affects, or could adversely affect, the health or welfare of a patient. Professional review actions involve a professional review activity, which occurs when the health care entity determines whether a practitioner may have clinical privileges, scope or condition of those privileges, or a change or modification of such privileges. In contrast, an administrative or employment action does not involve a professional review action related to professional competence or conduct that adversely affects, or could adversely affect, the health or welfare of a patient.

    In the scenario above, if a contract was not renewed or canceled for reasons other than clinical practice issues, it is not reportable. If a separate, but perhaps related, action was taken against the provider's clinical privileges, the entity would need to report that action to the NPDB. The best source for additional information is the NPDB Guidebook. There are Q&As that give some specific examples that might be helpful as well.

Other Attestation Related Topics

  1. How can we check our agency's point of contact listed in the NPDB and how can we update that information?

    The Data Bank administrator can sign into their account and select Administrator Options. Then select Maintain User Accounts where they can create a new user account or modify an existing user account. For additional information, see How to Manage User IDs and Passwords.

    If the Data Bank administrator is no longer with your organization, see How to Become the New Administrator.

    If you are trying to view or update the point of contact for your entity listed on reports, then the Data Bank administrator must sign into their account and select Administrator Options. Then select Update Registration Profile. This can also be updated during the registration renewal process.

  2. What are the three different roles in the NPDB Attestation Process?

    The three different roles in the NPDB Attestation process are:

    • Certifying Official is the person who certifies that everything the entity enters on the registration form is accurate;
    • Data Bank administrator is the person who organizes the entity's profile and user accounts; and
    • Attesting Official is the person who certifies that the entity has submitted all legally required reports during the two-year attestation timeframe.

    Note: An individual can serve in more than one role in the NPDB Attestation process. For example, one person can be the Certifying Official, Data Bank administrator, and Attesting Official.

  3. What are the costs for attestation?

    There are no costs for reporting or attesting.

  4. As a Health Center Program grantee and look-alike, we are questioning the charges attached to querying the system. With an ever-changing lineup of providers, this could be quite costly. Are there any alternatives to the NPDB?

    The NPDB does not receive any federal funding (appropriations) to support its operations. Therefore, according to Federal law the fees charged by the NPDB must cover the cost of operations. The NPDB has decreased its fees in recent years, and we continue to evaluate them regularly. The NPDB implemented continuous query as a way to provide a simpler and more valuable option, although that does not address frequently changing providers. With regard to other sources of data out there similar to the NPDB, there is no other comprehensive source of the type of information that is available in the NPDB. Information collected and provided by State Licensing Boards varies state to state, depending on state laws.

  5. If something is reported to the NPDB, how long does it take the NPDB to post it for queriers?

    After a report is submitted to the NPDB by a reporting entity, it takes one business day for the report to become available to queriers.

  6. What are the consequences if you fail to attest in a timely manner?

    If you fail to attest in a timely manner, we will follow up with you to determine what assistance may be needed.

  7. Is the Data Bank administrator the same person who attests for my health center?

    It depends. The Data Bank administrator may or may not attest for an organization. The person who attests needs to:

    • Have access to all potentially reportable actions taken by the entity;
    • Determine if any of those actions were reportable according to NPDB regulations;
    • Attest to whether or not all reportable actions taken during the Attestation time frame were submitted to the NPDB; and
    • Identify all site locations for which the organization makes decisions regarding credentialing and/or privileging.
  8. During the attestation process, I identified three actions that need to be reported to the NPDB. What should I do?

    Before you complete the Attestation form, we ask that you submit the three reportable actions to the NPDB. After you submit the reportable actions, you can log back into the NPDB and select yes on the Attestation form, attesting that you have submitted all the required reports.

  9. I use an agent for my querying and reporting to the NPDB. How does that affect this process of Attestation?

    You will complete the Attestation for your health center, regardless of whether or not you use an agent. If you discover that the agent has not reported all the required reports to the NPDB, it is your health center's responsibility to make sure that those reports are submitted.

  10. I answered "no" on the Attestation form indicating that my health center has not submitted all the required reports to the NPDB. After the reports are correctly submitted, can I go back and change my response to a "yes"?

    When you select no on the Attestation form, you are given the option to submit the required reports before submitting the Attestation form to the NPDB. However, once you have submitted the Attestation form to the NPDB, you cannot go back and change your response. Therefore, we ask that you submit all the required reports to the NPDB before submitting your Attestation form.


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