Data Bank Overview Data Bank Overview Reporting & QueryingReporting & Querying

Board of Certification Athletic Trainer Regulatory Conference

July 8 -9, 2011 July 8 -9, 2011

Bill West, M.A., R.N.U.S. Department of Health and Human Services

Health Resources and Services Administration

Bureau of Health Professions

Division of Practitioner Data Banks1

Presentation Overview

I. HRSA’s Bureau of Health Professions (BHPr), Division of Practitioner Data Banks

II. National Practitioner Data Bank (NPDB)

III. Section 1921 of the Social Security Act

IV. Healthcare Integrity and Protection Data Bank (HIPDB)

V. Compliance Activities

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HRSA’s Bureau of HRSA’s Bureau of Health ProfessionsHealth Professions

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BHPr MissionBHPr Mission

Increase the population’s access to health care

by providing national leadership in the

development, distribution and retention of a

diverse, culturally competent health workforce

that can adapt to the population’s changing

health care needs and provide the highest

quality of care for all. 4

Division of Practitioner Division of Practitioner Data BanksData Banks

The Division of Practitioner Data Banks

(DPDB), part of the Bureau of Health

Professions, is committed to the

development and operation of cost-

effective and efficient systems that offer

accurate, reliable, and timely information

on practitioners, providers, and suppliers

to credentialing, privileging and

government authorities.  5

Bureau of Health ProfessionsBureau of Health Professions

2010 Reorganization

Division of Public Health and

InterdisciplinaryEducation

Division of Medicine

and Dentistry

Division of Nursing

Division of Practitioner Data

Banks

Division of StudentLoans and

Scholarships

Division of Workforce andPerformanceManagement

National Center for

WorkforceAnalysis

Area Health EducationCenter Branch

Diversity Branch

Geriatrics andAllied Health Branch

Oral Health TrainingBranch

Primary CareMedical Education

Branch

Community-BasedTraining Branch

Advanced NursingEducation Branch

Community-BasedNursing Branch

Nursing Diversity and

Development BranchCompliance andDisputes Branch

Operations andAdministration Branch

Loan RepaymentPrograms Branch

HEAL Branch

Campus-BasedBranch

State WorkforceDevelopment Branch

Performance Managementand Program Evaluation

Branch

Office of Administrative Management Services

Office of Shortage Designation

Office of Policy Coordination

Office of the Associate Administrator

Office of SpecialInitiatives

Policy andResearch Branch

Public HealthBranch

Children’s HospitalTraining Branch 6

II. The National II. The National Practitioner Data Practitioner Data

BankBank

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National Practitioner Data BankNational Practitioner Data Bank(NPDB) (NPDB)

Laws and RegulationsLaws and Regulations

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The law’s intent is to restrict the

ability of incompetent physicians,

dentists, and other health care

practitioners to move from State to

State without disclosure of previous

medical malpractice payment and

adverse action history.

NPDBNPDB

• Established through Title IV of PublicLaw 99-660, the Health Care Quality Improvement Act of 1986 (HCQIA), as amended

• Part A – Promotion of Professional Review Activities– Established immunity provisions– Developed through case law, not Federal

regulations

• Part B – Reporting of Information– Established the NPDB

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NPDBNPDB

Overview of NPDBOverview of NPDB

• The NPDB serves primarily as an alert or flagging system to facilitate a comprehensive review

of health care practitioners' professional credentials.

• The information contained in the NPDB is meant to direct discrete inquiry into, and scrutiny of, specific areas of a practitioner's licensure, professional society memberships, medical malpractice payment history, and record of clinical privileges.

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Overview of NPDB Overview of NPDB (Continued)(Continued)

• The NPDB does not collect full records of reported incidents or actions and is not designed to be the sole source of information about a practitioner.

• If an NPDB report indicates that a settlement was made by or on behalf of a practitioner, it should not be assumed that negligence was involved.

• Credentialing and privileging should be an objective and circumspect process using all available resources to make an informed decision about a practitioner. 12

Querying the NPDBQuerying the NPDB

Hospitals Must Query by Law:

– When physicians, dentists, and other health care practitioners apply for staff appointments (courtesy or otherwise) or for clinical privileges; and

– Every 2 years on all physicians, dentists, and other health care practitioners who hold clinical privileges at the hospital.

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Querying the NPDB Querying the NPDB (Continued)(Continued)

The Following May Query the NPDB:

1. State licensing boards

2. Other health care entities with a formal peer review process

3. Professional societies with a formal peer review process

4. Health Care Providers (self-query only)

5. Researchers (non-identifying data only)14

III. Section 1921 of the Social Security Act

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Its intent is to protect beneficiaries

participating in the Social Security

Act’s health care programs from

unfit health care practitioners and

improve the anti-fraud provisions of

these programs.

Section 1921Section 1921

NPDB Expansion: Section NPDB Expansion: Section 19211921

Section 1921 of the Social Security Act– Expands the information collected and

disclosed by the NPDB

– Authorizes new types of organizations to query and receive Section 1921 information

– Requires new organizations to submit reports concerning practitioners and providers to the NPDB, such as state licensure boards for practitioners other than dentists or physicians, as well as for health care organizations

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Benefits of Section 1921Benefits of Section 1921

Benefits

• Access to expanded information enhances patient safety.

• HR departments can query to support employment decision-making for all licensed and certified health care practitioners to include but not limited to:

– Nurses, Physical Therapists, Pharmacists, Chiropractors, Paraprofessional Nurses, Optometrists, Podiatrists, Social Workers, Respiratory Therapists, etc.

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NPDB: Summary of Other NPDB: Summary of Other Provisions Provisions (Continued)(Continued)

• Health care entities can be sanctioned for failure to report or query (mandatory hospital queries only).

• NPDB information is confidential ($11,000 civil monetary penalty per violation).

• By law, the NPDB must recover full cost of operations. The current fee is $4.75 per query.

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NPDB: Summary of Other NPDB: Summary of Other ProvisionsProvisions

• Timeframe for reporting is within 30 days of the date of the adverse action or the date a medical malpractice payment was made.

• Medical malpractice payers and health care entities must send a copy of the NPDB report to the appropriate State licensing board.

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IV. Healthcare Integrity and Protection Data Bank

(HIPDB)

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Purpose: To deter fraud and

abuse in the health care system

and to promote quality health care

by collecting and disseminating

final adverse actions taken

against health care practitioners,

providers, and suppliers.

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HIPDB: Law and RegulationsHIPDB: Law and Regulations(Continued)(Continued)

HIPDB: Law and RegulationsHIPDB: Law and Regulations

• Established under Section 1128E of the Social Security Act as added by Section 221(a) of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

• Final regulations governing the HIPDB are codified at 45 CFR Part 61.

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NPDB ReportingNPDB Reporting

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Section 1921 expands the current NPDB adverse licensure action reporting requirements in two ways:

1. State licensing authorities must report adverse actions taken against all health care practitioners, not just physicians and dentists, as well as those actions taken against health care entities.

2. State licensing authorities must report all adverse licensure actions (not just those based on professional competence and conduct).• http://www.npdb-hipdb.hrsa.gov/resources/brochures/ReportingGuidance-PractitionerLicensureActions.pdf 25

NPDB: State Licensure Action NPDB: State Licensure Action Overview Overview

Summary of What Must Be Reported:

1.License revocations, restrictions, suspensions, surrenders, censures, reprimands, and probations

2.Any dismissal or closure of formal proceedings by reason of the practitioner or entity surrendering the license or leaving the State or jurisdiction

3.Voluntary surrenders or withdrawal of an application for license renewal or a denial of an application for license renewal, and licensure non-renewals (excluding those due to nonpayment of licensure renewal fees, retirement, or change to inactive status)

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NPDB: State Licensure NPDB: State Licensure Action Overview (Continued)Action Overview (Continued)

NPDB: State Licensure NPDB: State Licensure Action Overview (Continued)Action Overview (Continued)

4. Summary or emergency suspensions

5. Any negative action or finding that under the State’s law is publicly available information and is rendered by a licensing or certification authority, including, but not limited to, limitations on the scope of practice, liquidations, injunctions and forfeitures (This definition excludes administrative fines or citations, and corrective action plans, unless they are: connected to the delivery of health care services, or taken in conjunction with other licensure or certification actions such as revocation, suspension, censure, reprimand, probation, or surrender.)

6. Revisions to previously reported adverse licensure actions, such as reinstatement of a license

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Summary of What Not to Report:

1. Monitoring, continuing education, completion of other obligations (unless it constitutes a restriction, a reprimand, etc.)

2. Stayed actions

3. Voluntary relinquishment of license for personal reasons (e.g., retirement or change to inactive status)

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NPDB: State Licensure NPDB: State Licensure Action Overview (Continued)Action Overview (Continued)

NPDB Reports from September 1, 1990 through December 31, 2010

48.3%44.2%

5.0%

2.3% 0.1%

0.1%

NPDB Reports by Type (N = 803,843)

State Licensure: 48.3%, N=388,489

Medical Malpractice Payment: 44.2%, N= 355,102Exclusion/Debarment: 5%, N=40,227

Title IV Clinical Privileges: 2.3%, N=18,491

Professional Society: 0.1%, N=911

DEA/Federal Licensure: 0.1%, N=623

What Is in the NPDB Since Implementing Section 1921?

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1.4%

36.4%

51.9%

0.3%0.9%

8.8%

0.2%

NPDB Queries (N=59,429,343)

Self Queries - 858,278

Hospitals - 21,655,824

Health Plans - 30,859,762

Govt Programs - 175,763

State Licensing Agencies - 511,444

Other Service Providers - 5,222,738

Professional Societies - 145,534

NPDB Queries NPDB Queries

30NPDB Queries from September 1, 1990 through December 31, 2010

V. Compliance V. Compliance InitiativesInitiatives

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Compliance Focus:

• To ensure that the reporting and querying requirements are met by all mandated entities;

• To educate and provide technical assistance to reporting and querying entities; and

• To improve completeness and accuracy of reporting to the Data Bank.

Compliance OverviewCompliance Overview

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Compliance ActivitiesCompliance Activities

• Provide notice of non-compliance with reporting requirements for State Licensure Authorities

• Conduct regular data comparisons and provide results back to the State agencies for verification and the opportunity to report missing data

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Compliance Activities Compliance Activities (Continued)(Continued)

• Provide education and training to staff of State licensing boards on reporting licensure data

• Explore opportunities to make reporting easier

• Post compliance audit results

• Monitor eligibility of Data Bank Registrants

• Monitor violations of Confidentiality Rules

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2010 Compliance Initiatives 2010 Compliance Initiatives

First Initiative:• Identified State agencies responsible for licensing or

certifying health care providers• Compared list to data in the HIPDB• States received letters for “never reported”

professions in HIPDBSecond Initiative:

• Compared six frequently queried providers with HIPDB data (Nurses, Podiatrists, Pharmacists, Social Workers, Psychologists, and Physician Assistants)

• Gap Data sent to the boards for comparison and reconciliation

Third Initiative:• Compared physician and dentist boards disciplinary

actions with HIPDB data• Gaps in data sent to boards for comparison and

reconciliation

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Compliance Results PostedCompliance Results Posted

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Summary ReportsSummary Reports

Available at: http://www.npdb-hipdb.hrsa.gov/resources/aboutStatData.jsp

1.NPDB Reports on Individuals

2.NPDB Reports on Organizations

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51.6%

0.4%

9.2%

0.0%2.8%

0.1%0.9%

17.5%

0.7% 16.6%

NPDB Reports on Physicians, Nurses & Pharmacists

Physicians (MD, DO)

Physician Interns (MD, DO)

Dentists

Dental Assistants

Pharmacists

Pharmacist Interns and Assistants

Pharmacist Specialists and Technicians

Regsitered Nurses (RN)

Advanced Practice Nurses

Vocational Nurses, Nursing Assistants

NPDB Reports from September 1, 1990 through December 31, 2010

Top 10 Practitioner NPDB Reports by Top 10 Practitioner NPDB Reports by TypeType

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26.0%

25.6%19.2%

14.2%

15.0%

Five Most Frequently Cited Adverse Actions Against Individual Practitioners

Probation of License

Reprimand or Censure

Suspension of License

License Revoction

Exclusion from Medicare, Medicaid, Other Fed. Programs

Top 5 NPDB AARs by Type Top 5 NPDB AARs by Type

NPDB Reports from September 1, 1990 through December 31, 2010 39

Reference InformationReference Information

Web Site - www.npdb-hipdb.hrsa.gov

– NPDB and HIPDB Guidebooks– Interactive Training– FAQs, Brochures, and Fact Sheets– Statistics– Annual Reports– Instructions for Reporting and

Querying

Customer Service Center

– 1-800-767-6732 40

Contact InformationContact Information

Thank youThank youBill West, M.A, R.N.

Compliance Coordinator

U.S. Department of Health and Human Services

Health Resources and Services Administration

Bureau of Health Professions

Division of Practitioner Data Banks

Telephone: (301) 443-2300

Email: Wwest@hrsa.gov

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