National Practitioner Data Bank Disputes

The National Practitioner Data Bank (NPDB) was implemented by Congress in order to improve the quality of medical care and to restrict the ability of practitioners with a problematic past from moving from state to state and billing government health care programs. The regulations that govern the NPDB are laid out in 45 CFR part 60 and were implemented as a result of the Health Care Quality Improvement Act of 1983, 42 U.S.C. 11101 et seq. The NPDB requires certain entities to report any negative action taken against a health care practitioner within 15 days of a final action or summary suspension. Recent initiatives by HRSA (March 2010) make it clear the NPDB is trying to achieve full compliance from all reporting sources. In 2010 HRSA publicly posted the compliance status for nurses, pharmacists, physician assistants, psychologists, social workers, and in 2012 added all behavioral health professionals. In 2013 HRSA announced that they were focusing on the 12 most queried professionals: nurses, pharmacists, physician assistants, podiatrists, psychologists, social workers, physicians, dentists, chiropractors, optometrists, physical therapists, and behavioral health professionals. Recently, on May 6, 2013 the NPDB and the Healthcare Integrity and Protection Data Bank were consolidated into the NPDB.

National Practitioner Data Bank reporting entities are:

  • State Medical and Dental Boards
  • Hospitals and Health Care Entities
  • Professional Societies
  • Medical Malpractice Payers
  • Health Care Practitioners
  • Office of Inspector General (OIG), HHS

The main reporting entities that affect most health care professionals are: insurance carriers or anyone who makes an indemnity payment on behalf of the health care provider, hospitals or healthcare employers, and state licensing boards.

With respect to insurance indemnity payments the general rule is any payment made on your behalf to release you from a lawsuit is reportable. In the past physicians would be released and the hospital or corporations would assume liability to avoid reporting. This practice is no longer allowed. The payor must report the payment to the NPDB regardless of the amount.

With respect discipline, when a health care practitioner faces disciplinary action by their state licensing board, summary/emergency suspension of their license, or action taken by a credentialing body, a report must be sent to the NPDB within 15 days. Therefore, it is important to understand that when a physician, dentist, nurse, physician assistant or other health care practitioner is facing a licensing or credentialing issue they must contact a knowledgeable health law attorney. A health law attorney will work with you to limit or reduce the discipline, which results in no reporting or a more favorable report to the NPDB.

National Practitioner Data Bank Appeals

Negative information on the NPDB has the ability to ruin a health care practitioner’s career. Often, a practitioner with even one negative report can find it difficult to gain or maintain staff privileges, become excluded from billing large insurance companies and Medicare, and face subsequent state licensing actions. Health practitioners must exhaust every remedy to prevent damaging information from being disseminated to the NPDB.

Reports to the National Practitioner Data Bank are permanent but may be appealed through a dispute process and the subject of the report may also file a statement explaining the report. Initially, National Practitioner Data Bank disputes must be taken up with the reporting entity. The National Practitioner Data Bank will not handle disputes with the substance of a NPDB report. If the reporting entity fails to change the report after a request, the subject may request review of the report by the Secretary of HHS. The Secretary reviews reports only for accuracy of the factual information and to ensure that the information was required to be reported. The National Practitioner Data Bank dispute review process is highly technical and requires the knowledge and skill of an experienced health law attorney. Practitioners should be cautioned from filing disputes on their own with the Secretary of HHS because after an initial dispute is filed, the subject is unlikely to be granted a second review. There is no formal National Practitioner Data Bank appeals process for reconsideration of a Secretary’s review.

If you have received or are about to receive a negative National Practitioner Data Bank report and wish to appeal, you should contact Chapman Law Group immediately. Our experienced health law attorneys can fight to prevent damaging information from being shared on the NPDB and protect your rights during the appeals process.


National Practitioner Data Bank Dispute Process

 


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