Congress enacted the Health Care Quality Improvement Act (Title IV) in 1986, which created the National Practitioner Data Bank (NPDB). Since that time, three other laws have been ratified that have shaped the guidelines used today. Congress created the NPDB as a nationwide information clearinghouse to gather and publish matters related to the professional competence, quality, and behavior of health care professionals. Congress feared that physicians and dentists could move from state to state to evade any prior medical misadventures or inappropriate conduct. At the time, Congress perceived that a rising rate of malpractice litigation was commensurate with a declining quality of medical care provided. Irrespective of the legitimacy of this claim, the NPDB was born, and it survives today.
As with many other federal mandates (eg, EMTALA), the NPDB reporting guidelines have morphed considerably over the years. It will be a rare emergency physician who is not ensnared into the data bank from either a malpractice payment made on their behalf or other reasons related to their professional activities.
In October 2018, a new NPDB guidebook was released addressing updates and clarifications to the prior 2015 guidelines. The revised guidebook was designed to assist “eligible entities” to perform mandated reporting or queries of the data bank. Medical malpractice payers, hospitals, and professional societies are just some of the entities that are required to query and report various clinical outcomes to the data bank.
Information in the data bank that is available to eligible entities or those wishing to self-query their accounts includes medical malpractice payments, adverse actions related to licensure, changes in clinical privileging, professional society review actions of its members, Drug Enforcement Administration actions, and exclusions from federal health care programs (eg, Medicare and Medicaid). The totality of the guidelines can be viewed online at www.npdb.hrsa.gov/resources/aboutGuidebooks.jsp.
What Must Be Reported to NPDB?
- Medical malpractice payments
- Federal and state licensure and certification actions
- Adverse clinical privileges actions
- Adverse professional society membership actions
- Negative actions or findings by private accreditation organizations and peer-review organizations
- Health care–related criminal convictions and civil judgments
- Exclusions from participation in a federal or state health care program (including Medicare and Medicaid exclusions)
- Other adjudicated actions or decisions
Although the 2018 guidelines do not necessarily add novel pathways to end up in the data bank, there are significant clarifications focusing on any “restrictions” in clinical privileges.
Relevant Clarifications in the 2018 Updates
- An agreement to not exercise privileges or surrendering/restricting clinical privileges mandates NPDB reporting.
- Taking a leave of absence while under clinical investigation mandates NPDB reporting.
- Resignation while under a quality review plan (for clinical competence) or a quality review plan that lasts beyond 30 days in duration mandates NPDB reporting.
- Any state licensing or governing board’s adverse action against one of its licensees mandates NPDB reporting.
- Any adverse state licensing or board action that curtails a licensee’s practice of medicine due to mental illness, alcohol, or drug abuse mandates NPDB reporting.
- Surrendering a license, not under investigation, for mental illness, physical illness, or simply entering a substance abuse center is not reportable.
- Payment of a malpractice claim from a physician’s corporate account (PC, PA, PLLC, LLC, etc.) is reportable, while those payments made from their private funds or that of a group practice are not reportable.
In addition to the general inclusion rules noted above, the following are a few more obscure means by which emergency physicians in particular might find themselves included in the data bank.
What Emergency Physicians Need to Know
A professional society, such as ACEP, must report professional review actions based on reasons related to professional competence or professional conduct that adversely affect or may adversely affect the membership of a physician. The professional competence or professional conduct must adversely affect or potentially adversely affect the health or welfare of a patient. If, however, censure, reprimand, or admonishment is the sole result of an adverse membership action, that action should not be reported to the NPDB.
Hospitals and other health care entities (including entities that provide health care services and engage in professional review activities through a formal peer-review process for the purpose of furthering quality health care and professional societies of health care practitioners that engage in professional review activity through a formal peer-review process for the purpose of furthering quality health care) must report any involuntary restriction, modification, curtailment, or suspension of clinical privileges that exceeds 30 days in length. Any voluntary modification of clinical privileges by the clinician while under investigation must additionally be reported to the NPDB. This would include situations whereby the physician or dentist resigns while under investigation for incompetence or improper professional conduct (eg, claims of verbal abuse). An agreement to resign in exchange for the health care entity not performing an investigation would also fall within this reporting requirement.
Sanctions for Failing to Report to NPDB
Any malpractice payer that fails to report medical malpractice payments is subject to a civil money penalty of up to $11,000 for each such payment involved.
Any hospital or other health care entity that fails substantially to report adverse actions will have its name published in the Federal Register, and the organization will lose its immunity from liability under Title IV with respect to professional review activities for three years.
Any professional society that fails substantially to report adverse membership actions can lose immunity protections provided under Title IV for three years.
Any health plan failing to make a required NPDB report on an adverse action shall be subject to a civil money penalty of up to $25,000 for each adverse action not reported.
The NPDB is not just a repository for medical malpractice misadventures anymore. A criminal conviction, pattern of emotional lability in the workplace, or abrupt resignation following a bad clinical outcome could very well justify a mandatory reporting to the data bank. I would encourage all emergency physicians to at least be familiar with the NPDB guidelines, as inclusion in the data bank can adversely affect future job prospects and malpractice insurability.
NOTE: No information within this report should be construed as medical or legal advice. Independent medical and/or legal advice should be sought based on each individual’s particular circumstances.
Dr. Totz is facility medical director at First Choice Emergency Room at Adeptus Health in Texas.Multi-Page