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Overview Submitting Reports to the NPDB Reporting Medical Malpractice Payments Reporting Adverse Clinical Privileges Actions Reporting Adverse Professional Society Membership Actions Reporting State Licensure and Certification Actions Reporting Federal Licensure and Certification Actions Reporting Peer Review Organization Negative Actions or Findings Reporting Private Accreditation Organizations Negative Actions or Findings Reporting Exclusions from Participation in Federal and State Health Care Programs Reporting Federal or State Health Care-Related Criminal Convictions Reporting Health Care-Related Civil Judgments Reporting Other Adjudicated Actions or Decisions

Q&A: Reporting Exclusions from Federal
and State Health Care Programs

  1. The OIG pursued civil money penalties and exclusion against a physician because the physician and his medical practice allegedly billed Medicare improperly. The physician and his medical practice agreed to settle the case. The settlement did not include findings or admissions of liability, but the physician agreed to pay $100,000 for allegedly violating the Civil Money Penalties Law and agreed to be excluded from Medicare, Medicaid, and other Federal health care programs for 3 years. Should the civil money penalty or the exclusion, or both, be reported to the NPDB?

    The payment should not be reported because it was part of a settlement in which no findings or admissions of liability were made. Section 1128E specifically excludes from NPDB reporting any settlement that does not include an admission of liability. However, the exclusion must be reported. Exclusions that occur in conjunction with settlements in which no finding of liability has been made and that otherwise meet NPDB reporting requirements must be reported.

    If the settlement had included an admission of liability, it would have been reportable under 45 CFR §60.16 as an "other adjudicated action or decision." As defined in NPDB regulations, the settlement would have been a "formal or official final action[s]" that "include[d] the availability of a due process mechanism" and was "based on acts or omissions that affect or could affect the payment, provision, or delivery of a health care item or service."

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