What is Reportable to the NPDB?

The adverse actions that entities must report to the Department of Health & Human Services' National Practitioner Data Bank (NPDB) can matter a lot to your healthcare practice. To ensure that you appropriately monitor, update, and correct your NPDB record, you need to know what state licensing boards, employers, hospitals at which you hold privileges, and other reporters may and must report. NPDB reportable matters can ruin your healthcare reputation, relationships, and career. That's why you and other healthcare practitioners make periodic self queries of the NPDB to ensure that no entity has reported anything that is either inaccurate or that is not a reportable matter. Let us help you keep your NPDB record clean and clear, restricted to only accurate, up to date, and appropriately reportable matters. Retain the Lento Law Firm's premier Professional License Defense Team to help you address issues with your NPDB reportable matters. Call 888.535.3686 or complete this contact form now for our swift, strategic, and effective representation on NPDB reportable matters issues.

The National Practitioner Data Bank

Congress enacted the 1986 Health Care Quality Improvement Act for the Department of Health & Human Services to create the National Practitioner Data Bank (NPDB). Congress' intention was that the NPDB serve as a national clearinghouse for adverse action reports on healthcare practitioners. The idea was to protect patients and the public from harm due to substandard healthcare from the small percentage of healthcare practitioners who cause the great bulk of malpractice, abuse, neglect, and other wrongs. Before the NPDB's release in 1990, healthcare practitioner employers, hospitals granting privileges, state licensing boards, private health plans, and federal and state healthcare programs had to search multiple state databases, civil court files, criminal court cases, and similar sources for negative information on dangerous or potentially dangerous practitioners. HHS compiles and maintains the NPDB in readily searchable form to facilitate prompt and comprehensive searches. In theory, the NPDB should promote patient safety. In practice, though, the NPDB system can cause practitioners serious problems.

Who Gets Reported into the NPDB

Your first question about NPDB reportable matters may have to do with whether your healthcare field is among the practitioners whose adverse actions get reported into the NPDB. If you're not a qualifying healthcare practitioner, then you should have nothing about which to worry. However, the NPDB accepts reports against licensed healthcare practitioners broadly, without other limitations. HHS regulation 45 CFR 60.1 refers to “physicians, dentists, and other health care practitioners” and “health care entities, providers, and suppliers.” While HHS regulations specifically identify only physicians and dentists, the following catch-all provision and other healthcare practitioners essentially covers any other healthcare professional who holds a state license and may be subject to the reportable license actions, malpractice settlements and judgments, and reimbursement exclusions. If you're in the healthcare field as a licensed professional, you're likely subject to NPDB adverse action reports.

Who Reports into the NPDB

The first significant problem with NPDB reportable matters is that the NPDB has so many mandated reporters potentially reporting so much disparate, out of date, inaccurate, or disputable information. A healthcare practitioner's NPDB record can present a hornet's nest of problems. Reportable matters first depend on identifying the mandated NPDB reporters. HHS regulations 45 CFR §§ 60.7 through 60.16 require the following individuals and entities to report adverse actions into the NPDB:

• insurance companies making payments in settlement of malpractice matters, as §60.7 provides;
• boards of medical examiners taking adverse license actions, as § 60.8 provides;
• other state licensing or certification authorities taking adverse actions, as § 60.9 provides;
• federal licensing and certification agencies taking adverse actions, as § 60.10 provides;
• peer review organizations and private accreditation entities making negative actions or findings, as § 60.11 provides;
• healthcare entities employing or granting privileges to healthcare practitioners, when taking adverse actions, as § 60.12 provides;
• federal and state prosecutors gaining healthcare-related criminal convictions, as § 60.13 provides;
• federal and state attorneys and health plans gaining healthcare-related civil judgments, as § 60.14 provides;
• federal government agencies and state law and fraud enforcement agencies making exclusions from federal or state healthcare programs, as § 60.15 provides; and
• federal government agencies, state law or fraud enforcement agencies, and health plans, reaching other adjudicated actions of decisions, as § 60.16 provides.

NPDB Reportable Matters

The above paragraph summarizing HHS regulations on who must report into the NPDB also suggests the reportable matters. HHS regulation 45 CFR 60.5, titled “When information must be reported” and generally requiring reports within thirty days of the reportable event, separately states the matters that reporters must report. Rule 60.5 lists the following reportable matters:

• Malpractice payments, required under §60.7;
• Licensure and certification actions under §§ 60.8, 60.9, and 60.10;
• Negative actions or findings under § 60.11;
• Adverse actions under § 60.12;
• Healthcare-related criminal convictions under § 60.13;
• Healthcare-related civil judgments under § 60.14;
• Exclusions from federal or state healthcare programs under § 60.15; and
• Other adjudicated actions of decisions under § 60.16.

Why NPDB Reporting Matters

NPDB reporting matters because of who has access to the NPDB and the purposes for which they use it. Basically, the individuals and entities who most hold your healthcare practitioner license, employment, and privileges in their hands are the individuals and entities who have NPDB access. And those individuals and entities use the NPDB to make critical decisions about your healthcare license, employment, and privileges. Congress' Health Care Quality Improvement Act, 42 USC Section 11101 et seq., and the HHS regulations implementing the Act, do not grant everyone NPDB access. Only certain individuals and entities with certain intents may search the NPDB for certain purposes. Under HHS regulations CFR 45 CFR 60.17 and 60.18, HHS authorizes NPDB access for the following individuals and entities for the following purposes:

• state licensing boards, to evaluate candidates for licensure, license renewal, or license discipline;
• employers of healthcare professionals, to evaluate candidates for employment, employment discipline, and employment termination (employers must search the NPDB at hiring and within every two years of employment);
• hospitals, to evaluate candidates for privileges, restriction of privileges, or termination of privileges;
• attorneys suing hospitals for malpractice, when alleging that the hospital negligently failed to check the NPDB for the incompetent practitioner's adverse action reports;
• law enforcement agencies, for fraud and narcotics investigations;
• utilization and peer review organizations, for evaluation and statistics; and
• private health plans and public agencies administering healthcare programs, as well as participation and reimbursement.

How NPDB Reports Affect Healthcare Practitioners

NPDB reports can seriously affect and severely impact healthcare practitioners. You can already imagine from the above information just how harmful false, misleading, incomplete, or out of date NPDB adverse action reports could be on your reputation, relationships, and career. But consider here some of the specific risks you face from NPDB reportable matters.

License Actions and Loss from NPDB Reportable Matters

You already possess a healthcare practitioner license. You likely have to renew your license periodically, such as every two years. You may also be under a duty to report potentially disqualifying matters, subjecting you to license discipline and loss. But in the meantime, your licensing board may be periodically cross-referencing and monitoring the NPDB for adverse action reports against its licensed practitioners. Your NPDB reportable matter may cause your licensing board to charge you with discipline and suspend or revoke your license. Your NPDB reportable matter may also prevent you from obtaining a new license in another state or jurisdiction.

Loss of Privileges from NPDB Reportable Matters

You already have hospital privileges or other practice privileges at a healthcare facility that are important to your ability to care for your patients, carry out your employment, and earn your professional income. Your NPDB reportable matter, though, may lead your hospital to review, restrict, or terminate your privileges. Your hospital has the regulatory duty under 45 CFR 60.17 to check the NPDB for adverse action reports against you when you apply for privileges and every two years thereafter while holding privileges. You could lose your privileges to an NPDB reportable matter.

Loss of Public Program and Private Plan Participation

NPDB reportable matters can also cause you to lose your opportunity to participate, for reimbursement for your healthcare services, in private healthcare plans and state and federal healthcare programs. Healthcare plans and programs both report into the NPDB and search the NPDB for disqualifying adverse actions. Government programs in particular do not provide reimbursement for services supplied by practitioners who lose their licenses or suffer similar disqualifying events. If you lose the opportunity of your hospital, clinic, or other employer to receive reimbursement for your services, you won't get to perform those services.

Loss of Employment from NPDB Reportable Matters

The same discussion applies to your healthcare practitioner employment. Your employer may be a hospital, clinic, practice group, healthcare plan, healthcare system, or other entity. Entities employing licensed healthcare practitioners have the same duty under 45 CFR 60.16 to check your NPDB record on your hiring and every two years thereafter while you continue your employment. Employers may check your NPDB record more often, either out of their routine business and risk management practices or when they learn of information from which they suspect an adverse action report. Employers are ordinarily very sensitive to NPDB adverse action reports because of their potential malpractice liability for employing unqualified, unfit, or incompetent practitioners. Hospitals are deep pockets for malpractice claimants suffering serious injury, especially when the responsible healthcare practitioner has inadequate insurance policy limits. Do not expect your employer to tolerate adverse action reports reflecting potential unfitness for practice.

Loss of Relationships from NPDB Reportable Matters

In addition to license, privileges, and employment loss, you could also suffer loss of your professional relationships. If you lose your employment, those relationships can be critical to your obtaining replacement employment, perhaps in a managerial position that does not require licensure. Your professional network usually provides you with references and recommendation letters critical to gaining new employment. You could lose that support and other assistance your professional mentors, colleagues, and network provide you.

Loss of Financial Support from NPDB Reportable Matters

Of course, with loss of license, privileges, employment, and network support, you should expect to lose your professional income including important health insurance, retirement, and other benefits. You know the value of that income and those benefits. You also know your family members who depend on your support and the other obligations you have, such as court-ordered child support and educational, mortgage, and vehicle loans. Beware of the financial impact of NPDB reportable matters. Don't underestimate the potential financial losses when considering how to address your NPDB reportable matter issues.

Collateral Losses from NPDB Reportable Matters

Unfortunately, the above losses can in the worst cases snowball into other collateral effects, especially the mental and emotional distress and physical impacts from the stress of the above losses. Declines in your mental and physical condition associated with involuntary professional career changes can impact your family members and family relationships. On the whole, you should see that you have every reason to put your best effort into overcoming your NPDB reportable matter issues. And your best move is to retain our highly qualified attorneys to help you do so.

Common NPDB Reportable Matters Issues

Consider some common NPDB reportable matter issues that you may face. The next sections address how we help with these issues, how you avoid these issues, and the steps we may be able to take to gain a work around of these issues in the face of NPDB stalling. You may face one or more of the following common NPDB reportable matter issues:

• an individual or entity without the authority to report has made an adverse entry on your NPDB record;
• an individual or entity with reporting authority has made an inaccurate adverse entry on your NPDB record;
• an individual or entity with reporting authority has failed to update an outdated adverse NPDB record with exonerating information;
• an individual or entity with reporting authority has made an accurate but incomplete adverse action report, leaving a misleading adverse inference;
• you have been unable to invoke the NPDB's disputed status procedure for an inaccurate adverse action report;
• you have successfully invoked the NPDB's disputed status procedure for an inaccurate adverse action report but been unable to advance that procedure to the next dispute resolution procedure;
• you have advanced an inaccurate adverse action report to the NPDB dispute resolution procedure, but the NPDB won't act to resolve the dispute;
• you have advanced an inaccurate adverse action report to the NPDB dispute resolution procedure, but the NPDB erroneously resolved the dispute against you, leaving the inaccurate report in place;
• the NPDB resolved the inaccurate adverse action report procedure in your favor but did not make the proper correction in your NPDB record; and
• NPDB officials have failed or refused to respond to your inquiries and communications regarding an inaccurate adverse action report and its proper resolution in your favor.

How We Help with NPDB Reportable Matters Issues

No need for you to feel helpless in the face of your NPDB reportable matter issues. Let our highly qualified attorneys go to work for you, resolving those issues. We have a national reputation and relationships of trust, confidence, and respect among officials involved in NPDB reportable matters. We also have the diplomatic skills, law knowledge, and administrative procedure experience to take the right strategic approach toward prompt and favorable resolution. When we contact NPDB staff members, our appearance as attorneys on your behalf gains their attention. We can move the matter up through the organization's hierarchy and call on other organization and agency officials to intervene as necessary, to get the action you need.

Your matter may also present the opportunity for our attorneys to reach out to HHS oversight officials to gain accountability for NPDB staff. When we do get an NPDB response, we can promptly provide the authenticated and verified documentation that NPDB staff members request, in a form on which they can rely. Our role as licensed attorneys, with our duty to always act honestly and forthrightly without misleading, can reassure NPDB staff that your documentation and representations are accurate.

Invoking NPDB Resolution Procedures

While we are often able to resolve NPDB reportable matter issues informally, with communication and negotiation, we are also prepared to help you invoke the NPDB disputed status and dispute resolution procedures. HHS regulation 45 CFR 60.21 sets forth the NPDB disputed status procedure, through which we can alert NPDB officials and those searching the NPDB that you maintain that an adverse action report is inaccurate or out of date. The same regulation provides for the NPDB dispute resolution procedure. We can help you follow the specific procedure the NPDB requires to advance your inaccurate adverse action report from disputed status, to the dispute resolution procedure, and then on through the dispute resolution procedure to the NPDB decision. We can also help you challenge an adverse NPDB decision. Let us go to work for you invoking NPDB procedures.

Workarounds for NPDB Reportable Matter Issues

We may have another way to address your NPDB reportable matter issue, beyond invoking NPDB procedures. Reporting individuals and entities accused of making an inaccurate NPDB adverse action report are often hesitant to accept the healthcare practitioner's self-advocacy. They may already distrust the healthcare practitioner whose incompetence or unprofessionalism they've already reported. However, we may be able to convince the reporting individual or entity otherwise using our reputation and advocacy skills and properly presenting your documentation and attestations. We may be able to convince the reporter of its error and further convince it to voluntarily revise, correct, update, or withdraw the adverse action report, without even requiring NPDB dispute resolution.

Grounds to Correct NPDB Reportable Matter Issues

Our attorneys may also be able to give the individual or entity making the inaccurate adverse action report better reasons to promptly make a correction. That reporter could have defamation liability for your loss associated with its inaccurate NPDB adverse action report. HHS regulation 45 CFR 60.22 grants immunity from civil liability for NPDB adverse action reports only when the reporter makes the report in good faith. The regulation eliminates the immunity on a showing that “the individual, entity, or authorized agent submitting the report has actual knowledge of the falsity of the information contained in the report.” Our advocacy with the reporter may not only convince the reporter that its adverse action report is false but also that the reporter faces civil liability for your potential or actual substantial losses if it does not promptly withdraw the erroneous report.

How to Avoid NPDB Reportable Matters

If at the same time you have reportable matters pending with your state licensing board, hospital, employer, or health plan or program, we can also help you head off the NPDB adverse action report. The strategy is that a report never made is better than a report corrected through elaborate procedures. Healthcare practitioners often have notice that an individual or entity may pursue license discipline, or termination of privileges, employment, or plan or program participation. You can often see it coming. If that's your case, then promptly retain us to address and favorably resolve the matter before it results in the feared adverse action and becomes part of your NPDB record. We can respond to a licensing board investigation or charge with your exonerating and mitigating evidence. We can also communicate and advocate with your hospital, employer, and plan or program to address their concerns over your fitness, competence, professionalism, or other performance.

Premier NPDB Reportable Matters Representation

If you face National Practitioner Data Bank reportable matter issues, retain the Lento Law Firm's premier Professional License Defense Team to help you favorably resolve those issues. Call 888.535.3686 or complete this contact form now for our highly qualified representation, for your best NPDB reportable matter outcome.