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HCQIA Reporting

HCQIA requires NPDB reporters to report medical malpractice payments and adverse actions taken on or after September 1, 1990. With the exception of reports on Medicare or Medicaid exclusions, the NPDB cannot accept any report with a date of payment or a date of action prior to September 1, 1990. State licensing boards, hospitals, other health care entities, and professional societies are expected to identify, discipline, and report on those who engage in unprofessional behavior. With the addition of Section 1921, HCQIA reporting requirements did not change for hospitals, other health care entities, medical malpractice payers and insurers, professional societies with formal peer review processes, the Drug Enforcement Administration (DEA), or the HHS Office of Inspector General (OIG) (See below).

Exclusions from certain Federal Government health care programs are also part of the NPDB. In 1997, an interagency agreement between HHS' Health Resources and Services Administration (HRSA), the Centers for Medicare & Medicaid Services (CMS), and the HHS OIG included Medicaid and Medicare exclusions in the NPDB. Later that same year, the NPDB made CMS reinstatement reports available to registered users. Thus, Adverse Action Reports submitted to the NPDB expanded to include practitioner exclusions from Medicare and Medicaid in addition to adverse licensure and professional review actions related to clinical privileges and professional society memberships.

Section 1921 Reporting

Section 1921 added State licensure actions taken against all types of health care practitioners, not just physicians and dentists, to the NPDB. The section also expanded NPDB reporting requirements to include negative actions or findings by State licensing agencies, peer review organizations, and private accreditation organizations against all health care practitioners and organizations. The following is a description of the reporting requirements under Section 1921.

NPDB Reporters with New Responsibilities under Section 1921

  • Boards of medical or dental examiners report:
    • Adverse licensure actions against a health care practitioner (not just actions related to competence or conduct against physicians and dentists).
    • Any negative action or finding by a State licensing authority against a health care practitioner or entity.1

New NPDB Reporters under Section 1921

  • Other State practitioner licensing boards report:
    • Adverse licensure actions against a health care practitioner. Any negative action or finding by a State licensing authority against a health care practitioner.
  • State health care entity licensing authorities report:
    • Adverse licensure actions against a health care entity. Any negative action or finding by a State licensing authority against a health care entity.
  • Private accreditation organizations report:
    • Certain final actions taken by the private accreditation organization against a health care entity.
  • Peer review organizations report:
    • Recommendations by the peer review organization to sanction a health care practitioner.

Combined HCQIA and Section 1921 Reporting

In summary, the following entities are required to report to the NPDB:

  • State medical and dental boards;
  • State licensing boards for all other health care practitioners;
  • State agencies that license health care entities;
  • Hospitals;
  • Other health care entities or organizations;
  • Professional societies that follow a formal peer review process;
  • Medical malpractice payers;
  • Private accreditation organizations; and
  • Peer review organizations.

Government Reporting

Reports are collected from private and government entities, including the Armed Services, located in the 50 states and U.S. territories.2 To obtain information from government entities, the Secretary of HHS entered into memorandums of agreement (MOA) with all relevant Federal agencies and departments. Section 432(b) of the Social Security Act required the Secretary to establish an MOA with the Secretaries of Defense and Veterans Affairs to apply provisions of the SSA to hospitals, other facilities, and health care providers under their jurisdictions. Section 432(c) stipulated that the Secretary also enter into an MOA with the administrator of the Department of Justice, Drug Enforcement Administration (DEA) to ensure the reporting of practitioners whose registrations to dispense controlled substances are suspended or revoked under section 304 of the Controlled Substances Act.

The Secretary of HHS has government agreements in place with the following agencies to ensure compliance with all NPDB-related laws.

  • Centers for Medicare & Medicaid Services (Interagency Agreement);
  • Department of Defense (MOA);
  • Department of Justice, which includes the Bureau of Prisons and the DEA (MOA);
  • Department of Veterans Affairs (MOA); and
  • Public Health Service contractors and employees (HHS Policy Directive).