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

1. Data Bank Overview Reporting & Querying Board of Certification Athletic Trainer Regulatory Conference 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 Banks

2. Presentation Overview • HRSA’s Bureau of Health Professions (BHPr), Division of Practitioner Data Banks • National Practitioner Data Bank (NPDB) • Section 1921 of the Social Security Act • Healthcare Integrity and Protection Data Bank (HIPDB) • Compliance Activities

3. HRSA’s Bureau of Health Professions 3

4. BHPr 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

5. Division of Practitioner Data 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

6. Office of the Associate Administrator Office of Administrative Management Services Office of Shortage Designation Office of Policy Coordination Bureau of Health Professions Division of Public Health and Interdisciplinary Education Division of Medicine and Dentistry Division of Nursing Division of Practitioner Data Banks Division of Student Loans and Scholarships Division of Workforce and Performance Management National Center for Workforce Analysis Campus-Based Branch Geriatrics and Allied Health Branch Primary Care Medical Education Branch Advanced Nursing Education Branch Performance Management and Program Evaluation Branch Policy and Research Branch Area Health Education Center Branch Oral Health Training Branch Nursing Diversity and Development Branch State Workforce Development Branch Compliance and Disputes Branch HEAL Branch Diversity Branch Community-Based Training Branch Community-Based Nursing Branch Office of Special Initiatives Operations and Administration Branch Loan Repayment Programs Branch Children’s Hospital Training Branch Public Health Branch 6 2010 Reorganization

7. II. The National Practitioner Data Bank 7

8. National Practitioner Data Bank(NPDB) Laws and Regulations 8

9. NPDB 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. 9

10. Established through Title IV of Public Law 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 NPDB 10

11. Overview 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. 11

12. Overview of NPDB (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

13. Querying 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. 13

14. Querying the NPDB (Continued) The Following May Query the NPDB: • State licensing boards • Other health care entities with a formal peer review process • Professional societies with a formal peer review process • Health Care Providers (self-query only) • Researchers (non-identifying data only) 14

15. III. Section 1921 of the Social Security Act

16. Section 1921 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. 16

17. NPDB Expansion: Section 1921 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 17

18. Benefits 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. 18

19. NPDB: Summary of Other Provisions (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. 19

20. NPDB: Summary of Other Provisions 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. 20

21. IV. Healthcare Integrity and Protection Data Bank (HIPDB)

22. HIPDB: Law and Regulations (Continued) 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. 22

23. HIPDB: 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. 23

24. NPDB Reporting 24

25. NPDB: State Licensure Action Overview Section 1921 expands the current NPDB adverse licensure action reporting requirements in two ways: • 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. • 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

26. NPDB: State Licensure Action Overview (Continued) Summary of What Must Be Reported: • License revocations, restrictions, suspensions, surrenders, censures, reprimands, and probations • Any dismissal or closure of formal proceedings by reason of the practitioner or entity surrendering the license or leaving the State or jurisdiction • 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) 26

27. NPDB: State Licensure Action Overview (Continued) • Summary or emergency suspensions • 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.) • Revisions to previously reported adverse licensure actions, such as reinstatement of a license 27

28. NPDB: State Licensure Action Overview (Continued) Summary of What Not to Report: • Monitoring, continuing education, completion of other obligations (unless it constitutes a restriction, a reprimand, etc.) • Stayed actions • Voluntary relinquishment of license for personal reasons (e.g., retirement or change to inactive status) 28

29. What Is in the NPDB Since Implementing Section 1921? NPDB Reports from September 1, 1990 through December 31, 2010 29

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

31. V. Compliance Initiatives 31

32. 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 Overview 32

33. Compliance 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 33

34. Compliance Activities (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 34

35. 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 HIPDB • Second 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 35

36. Compliance Results Posted 36

37. Summary Reports • Available at: • http://www.npdb-hipdb.hrsa.gov/resources/aboutStatData.jsp • NPDB Reports on Individuals • NPDB Reports on Organizations 37

38. Top 10 Practitioner NPDB Reports by Type NPDB Reports from September 1, 1990 through December 31, 2010 38

39. Top 5 NPDBAARs by Type NPDB Reports from September 1, 1990 through December 31, 2010 39

40. Reference 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

41. Contact Information Thank you Bill 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 41