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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

Reporting Other Adjudicated Actions or Decisions

Federal agencies, State law enforcement agencies, State Medicaid fraud control units, State agencies administering or supervising the administration of a State health care program, and health plans must report other adjudicated actions or decisions against health care practitioners, providers, and suppliers (regardless of whether the action or decision is subject to a pending appeal). Among the specified State agencies, only the State agency that takes an adjudicated action or decision against a health care practitioner, provider, or supplier is responsible for reporting that action to the NPDB.

Table E-25 outlines reporting obligations for other adjudicated actions or decisions.

Law Who Reports? What is Reported? Who is Reported?
Section 1921 State law enforcement agencies*

State Medicaid fraud control units*

State agencies administering or supervising the administration of a State health care program*
Other adjudicated actions or decisions Practitioners, providers, and suppliers
Section 1128E Federal attorneys

Health plans
Other adjudicated actions or decisions Practitioners, providers, and suppliers

* NPDB regulations define "State law or fraud enforcement agency" as including but not limited to these entities.

The term "other adjudicated actions or decisions" means:

  • Formal or official final actions taken against a health care practitioner, provider, or supplier by a Federal agency, State law enforcement agency, State Medicaid fraud control unit, State agency administering or supervising the administration of a State health care program, or health plan;
  • That include the availability of a due process mechanism; and
  • That are based on acts or omissions that affect or could affect the payment, provision, or delivery of a health care item or service.

A hallmark of any valid adjudicated action or decision is the availability of a due process mechanism. The fact that the subject elects not to use the due process mechanism provided by the authority bringing the action is immaterial, as long as such a process is available to the subject before the adjudicated action or decision is made final. In general, if an adjudicated action or decision follows an agency's established administrative procedures (which ensure that due process is available to the subject of the final adverse action), it would qualify as a reportable action under this definition. For health plans that are not government entities, an action taken following adequate notice and the opportunity for a hearing that meets the standards of due process set out in Title IV also would qualify as a reportable action under this definition.

The definition of "other adjudicated action or decision" specifically excludes the following:

  • Clinical privileges actions and similar paneling decisions made by health plans
  • Overpayment determinations and denial of claims determinations
  • Business or administrative decisions taken by health plans that result in contract terminations unrelated to health care fraud, abuse, or quality of care (e.g., a practitioner's contract is terminated because the practitioner no longer practices at a facility in the health plan's network; a health plan terminates all provider contracts in a certain geographic area because it ceases business operations in that area)

Settlements in which no findings or admissions of liability have been made are statutorily excluded from being reported. However, actions that occur in conjunction with settlements in which no findings of liability have been made and that otherwise meet NPDB reporting requirements must be reported.

Actions with respect to medical malpractice claims should not be reported in this category.

Federal agencies, State law enforcement agencies, State Medicaid fraud control units, State agencies administering or supervising the administration of a State health care program, and health plans also must report any revisions to a previously reported other adjudicated action or decision, including whether the action is on appeal. For more information, go to Types of Reports in this chapter.

Table E-26 provides guidance on when other adjudicated actions or decisions must be reported to the NPDB. Table E-27 describes which reporting format should be used for reporting other adjudicated actions or decisions to the NPDB.

Action
Reportable?
A health plan's termination of a practitioner's contract based on poor patient care, after the practitioner was afforded due process. Yes
A health plan's personnel-related suspension of a practitioner for violating infection control procedures, after the practitioner declined to avail himself of the due process mechanism. Yes
A Federal agency's reduction of a practitioner's pay for failure to appropriately supervise the delivery of health care services, after the practitioner exhausted her due process rights. Yes
An overpayment determination against a practitioner made by a Federal or State health care program, its contractor, or a health plan. No
A denial of claim determination against a practitioner made by a Federal agency. No
A health plan's decision to terminate a contract with a physician based on business or administrative reasons (e.g., the physician is retiring). No
Type of Action NPDB Reporting Format
Other adjudicated actions or decisions taken by a Government agency Government Administrative Action on the Adverse Action Report format
Other adjudicated actions or decisions taken by a health plan Health Plan Action on the Adverse Action Report format

Other Adjudicated Actions or Decisions Taken in Conjunction with Clinical Privileges Actions

Certain Federal and State agencies and health plans that are required to report other adjudicated actions or decisions also may be required to report clinical privileges actions if those actions meet NPDB reporting requirements. However, because the definition of other adjudicated actions or decisions specifically excludes clinical privileges, if an entity takes both a clinical privileges action and another adjudicated action or decision, the entity must report them separately.

For example, if a health plan takes a network participation action that meets the NPDB reporting requirements for an adverse clinical privileges action in conjunction with a contract termination that meets the definition of an "other adjudicated action or decision," each action must be reported separately. When submitting these actions to the NPDB, the health plan must submit two reports: the health plan must report the network participation action as a Clinical Privileges Action on the NPDB's Adverse Action Report format; in addition, it must report the contract termination (which is another adjudicated action or decision) as a Health Plan Action on the Adverse Action Report format.

Sanctions for Failing to Report to the NPDB

If HHS determines that a Federal agency, a State law enforcement agency, a State Medicaid fraud control unit, or a State agency administering or supervising the administration of a State health care program has substantially failed to report information required to be reported to the NPDB, the name of the entity will be published and made publicly available.

Any health plan that fails to report information on an adverse action required to be reported to the NPDB will be subject to a civil money penalty of up to $25,000 for each such adverse action not reported. Such penalty will be imposed and collected in the same manner as civil money penalties under Section 1128A(a) of the Social Security Act.

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