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Chapter E: Reports
Overview
The NPDB is a confidential information clearinghouse created by Congress with the primary goals of improving health care quality, protecting the public, and reducing health care fraud and abuse in the United States. Acting primarily as a national flagging system, the NPDB provides information that permits queriers to perform comprehensive reviews of the credentials of health care practitioners, entities, providers, and suppliers. The NPDB collects information on medical malpractice payments and certain adverse actions and discloses that information to eligible entities. These payments and actions are required to be reported to the NPDB under Title IV of Public Law 99-660, the Health Care Quality Improvement Act of 1986 (Title IV); Section 1921 of the Social Security Act (Section 1921); Section 1128E of the Social Security Act (Section 1128E); and their implementing regulations found at 45 CFR Part 60.
Entities that are required to report to the NPDB include medical malpractice payers, hospitals and other health care entities, professional societies, health plans, peer review organizations, private accreditation organizations, federal government agencies, state law enforcement agencies, state Medicaid fraud control units, state agencies administering or supervising the administration of a state health care program, and state licensing and certification authorities (including state medical and dental boards). The information required to be reported to the NPDB concerns health care practitioners, entities, providers, and suppliers.
The NPDB is meant to be used as one of many tools available to health care entities of all types as they make licensing, certification, hiring, credentialing, contracting, and similar decisions. The NPDB can provide valuable background information, but health care entities should use the NPDB in conjunction with other resources when making personnel and contracting decisions.
Reporting Requirements
Eligible entities are responsible for meeting specific querying and/or reporting requirements and must register with the NPDB in order to query or report to the NPDB. Entities may qualify as more than one type of eligible entity. In such cases, the entity must comply with all associated querying and reporting responsibilities.
Table E-1: Summary of Reporting Requirements, Part 1
| Law | Who Reports? | What is Reported? | Who is Reported? |
|---|---|---|---|
| Title IV | Medical malpractice payers, including hospitals and other health care entities that are self-insured | Medical malpractice payments resulting from a written claim or judgment | Practitioners |
| State medical and dental boards | Certain adverse licensure actions related to professional competence or conduct (Medical and dental boards that meet their reporting requirements for Section 1921, described in Part 2 of this table, will also meet their requirements to report under Title IV) |
Physicians and dentists | |
| Hospitals Other health care entities with formal peer review |
Certain adverse clinical privileges actions related to professional competence or conduct | Physicians and dentists Other practitioners (optional) |
|
| Professional societies with formal peer review | Certain adverse professional society membership actions related to professional competence or conduct | Physicians and dentists Other practitioners (optional) |
|
| DEA | DEA controlled-substance registration actions* | Practitioners | |
| OIG | Exclusions from participation in Medicare, Medicaid, and other federal health care programs* | Practitioners |
* This information is reported to the NPDB under Title IV based on a memorandum of understanding.
Table E-1: Summary of Reporting Requirements, Part 2
| Law | Who Reports? | What is Reported? | Who is Reported? |
|---|---|---|---|
| Section 1921 | Peer review organizations | Negative actions or findings by peer review organizations | Practitioners |
| Private accreditation organizations | Negative actions or findings by private accreditation organizations | Entities, providers, and suppliers | |
| State licensing and certification authorities | State licensure and certification actions | Practitioners, entities, providers, and suppliers | |
| State law enforcement agencies* State Medicaid fraud control units* State agencies administering or supervising the administration of a state health care program* State prosecutors |
Exclusions from participation in a state health care program Health care-related civil judgments in state court Health care-related state criminal convictions Other adjudicated actions or decisions |
Practitioners, providers, and suppliers | |
| Section 1128E | Federal agencies Federal prosecutors Health plans |
Federal licensure and certification actions** Health care-related civil judgments in federal or state court Health care-related criminal convictions in federal or state court** Exclusions from participation in a federal health care program** 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.
** Reported only by federal agencies.
The reporting requirements summarized in Table E-1 are described in greater detail in this chapter. As shown in the table, each of the three major statutes governing NPDB operations has its own reporting requirements. In some instances, actions must be reported based on memorandums of understanding. In certain cases, requirements may exist under more than one statute, or under both a statute and a memorandum of understanding. For example, as discussed in Chapter B: Eligible Entities, the Drug Enforcement Administration's (DEA's) controlled-substance registration actions are reported to the NPDB under Title IV based on a memorandum of understanding; the Department of Health and Human Services (HHS) Office of Inspector General's (OIG's) exclusions from Medicare, Medicaid, and other federal health care programs are reported to the NPDB under Title IV based on an interagency agreement. Both DEA and OIG actions also must be reported to the NPDB under Section 1128E.
Terminology Differences
An action must be reported to the NPDB based on whether it satisfies NPDB reporting requirements and not based on the name affixed to the action by a reporting entity. For example, whether an administrative fine is reportable to the NPDB depends upon whether the fine meets NPDB reporting requirements, not on the name affixed to the fine. A suspension or restriction of clinical privileges is reportable if it meets reporting criteria, whether the suspension or restriction is called summary, immediate, emergency, precautionary, or any other term.
Time Frame for Reporting
Eligible entities must report medical malpractice payments and other required actions to the NPDB within 30 calendar days of the date the action was taken or the payment was made.
The time frame for reporting each type of action described in Table E-1 is summarized in Table E-2.
| Types of Actions that Must Be Reported | When Information Must be Reported |
|---|---|
| Medical malpractice payments Certain adverse licensure actions related to professional competence or conduct (reported under Title IV) Certain adverse clinical privileges actions related to professional competence or conduct Certain adverse professional society membership actions related to professional competence or conduct DEA controlled-substance registration actions on practitioners (reported under Title IV) Exclusions from participation in Medicare, Medicaid, and other federal health care programs (reported under Title IV) |
Within 30 days of the date the action was taken or the payment was issued, beginning with actions occurring on or after September 1, 1990 |
| Negative actions or findings taken by peer review organizations Negative actions or findings taken by private accreditation organizations |
Within 30 days of the date the action was taken, beginning with actions occurring on or after January 1, 1992 |
| State licensure and certification actions Federal licensure and certification actions Health care-related criminal convictions in federal or state court Health care-related civil judgments in federal or state court Exclusions from participation in a federal or state health care program. Other adjudicated actions or decisions |
Within 30 days of the date the action was taken, beginning with actions occurring on or after August 21, 1996 |
The NPDB cannot accept reports with a date of payment or a date of action prior to September 1, 1990, with the exception of Medicare and Medicaid exclusions submitted by the OIG.
If an eligible entity discovers documentation of medical malpractice payments, adverse actions, or judgments or convictions that the eligible entity had not reported to the NPDB, the entity must promptly submit the related report(s). All required reports must be filed with the NPDB regardless of whether they are late.
Entities are not excused from reporting simply because they missed a reporting deadline. The Secretary of HHS will conduct an investigation if there is reason to believe an entity substantially failed to report required medical malpractice payments or adverse actions. Entities have the opportunity to correct the noncompliance (see "Sanctions for Failing to Report to the NPDB" in the sections discussing the reporting requirement for each type of action).
Deceased Practitioners
One of the principal objectives of the NPDB is to restrict the ability of incompetent physicians, dentists, and other health care practitioners to move from state to state without the disclosure or discovery of their previous damaging or incompetent performance. Reports concerning deceased practitioners must be submitted to the NPDB because a fraudulent practitioner could assume the identity of a deceased practitioner. When submitting a report on a deceased practitioner, indicate that the practitioner is deceased in the appropriate data field.
Report Retention
Information reported to the NPDB is maintained permanently in the NPDB, unless it is corrected or voided from the NPDB by the reporting entity or by the NPDB as a result of the Dispute Resolution process.
Civil Liability Protection
The immunity provisions in Title IV, Section 1921, and Section 1128E protect individuals, entities, and their authorized agents from being held liable in civil actions for reports made to the NPDB unless they have actual knowledge of falsity of the information contained in the report. These provisions provide the same immunity to HHS in maintaining the NPDB.
Official Language
The NPDB's official language is English. All reports must be submitted in English. Files submitted in any other language or containing non-alphanumeric characters (e.g., tildes, accents, umlauts) are not accepted.
