Why the National Practitioner Data Bank Matters to You and

Your Clients

Mark V. Gende, Esq.Sweeny, Wingate & Barrow, PA

Columbia, South Carolina

What is the NPDB?

• Information clearing house• Collect and release certain information• Professional competence and conduct• Physicians• Dentists• Other health care practitioners

Why did Congress Create NPDB?

• Increasing medical malpractice litigation• Need to improve quality of medical care• National problem states unable to address• Restrict incompetent physicians movement• Promote effective peer review by– Incentives (fines)– Protection (confidentiality)

• Reduce health care fraud and abuse (NIPDB)

A Brief History of the NPDB• Health Care Quality Improvement Act of 1986

(Title IV)• Medicare and Medicaid Patient and Protection

Act of 1987 (Section 1921; NPDB)• Health Insurance Portability and Accountability

Act of 1996 (Section 1128E; HIPDB)• Patient Protection and Affordable Care Act of

2010 (merge NPDB and HIPDB)

The Merger of NPDB and NIPDB• NIPDB consolidated with NPDB May 6, 2013• Final regulations published April 5, 2013,

Codified at 45 CFR Part 60• Draft NPDB Guidebook published November

2013• Comment period on Revised NPDB Guidebook

closes on February 5, 2014• New NPDB Guidebook will be posted at

http://www.npdg.hrsa.gov

What about the NPDB isimportant to litigators?

• Basic reporting requirements• Basic querying access• Where you are likely to encounter the NPDB• The NPDB web site

Basic Reporting

• Who is reported?– Physicians– Dentists– Other practitioners– Entities– Providers– Suppliers

Basic Reporting

• Who reports?– Medical malpractice payers– Hospitals– Other self-insured healthcare entities– Professional societies– Health plans– Peer review organizations– Various State and Federal agencies

Basic Reporting

• What is reported?– Medical malpractice payment from• A written claim• A judgment

– Certain adverse clinical privileges actions– Certain adverse professional society membership

actions– DEA controlled substances registration actions– Exclusions from Medicare, Medicaid

Basic Reporting

• When is a report made?– Within 30 days from• Date action taken• Date payment made

• What are the basic report formats?– Medical Malpractice Payment Report (MMPR)– Judgment or Conviction Report– Adverse Action Report

Basic Reporting

• What is in a report?– Age of claimant– Sex of claimant– Patient type (in or out)– Initial Event (medical condition of patient)– Procedure performed– Claimant’s allegation– Associated legal and other issues– Outcome

Basic Reporting

• Example of a MMPRA 65-year-old male outpatient had a prostate exam by Dr. A. Six months later, the patient was diagnosed by Dr. B with prostate cancer and underwent surgery. One year later, the patient sued Dr. A for alleged failure to diagnose. A settlement was reached in the amount of $250,000.

(Source: NPDG Guidebook, September 2001)

Basic Querying

• What is querying?– Ability to access NPDB reports

• Who must/may/may not query?– Hospitals (must)– State licensing boards– Professional societies– Other health care entities– Attorneys– Physicians, dentists, practitioners concerning self– Medical malpractice payers (cannot)

Attorney Querying

• Plaintiffs’ attorneys– Filed medical malpractice action/claim– Against hospital– Evidence reveals hospital failed to query– Practitioner also named in the action/claim

• Defense attorneys– Not permitted to query– Defendant practitioner can self-query

NPDB and the Litigator

• Advise your client early about NPDB reporting– As it relates to settlement– As it relates to reporting– Memorialize your advice

• Clients surprised by NPDB reporting– File grievances– May impact representation opportunities• With other medical providers• With your carrier

NPDB and the Litigator

• Carrier asks you to draft the report– Consult the Guidebook– Coordinate draft with carrier– Coordinate draft with client– Memorialize all communications

NPDB and the Litigator

• Challenging a filed report– Retained by a practitioner– Well defined appeals process– Typically courts have upheld the NPDB

Leaning More about the NPDB

• The Draft NPDB Guidebook• The U.S. Department of Health and Human

Services web site– http://www.npdb.hrsa.gov– Wealth of interesting statistical information– Statistical Data / NPDB research statistics

United States

South Carolina (all practitioners)

South Carolina (physicians)