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Overview of Data Bank Reporting Requirements

Utah Association of Medical Staff Services (UAMSS) One Day Seminar August 12, 2011. Overview of Data Bank Reporting Requirements. Elizabeth Rezaizadeh, MPH U.S. Department of Health and Human Services Health Resources and Services Administration Bureau of Health Professions

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Overview of Data Bank Reporting Requirements

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  1. Utah Association of Medical Staff Services (UAMSS) One Day SeminarAugust 12, 2011 Overview of Data Bank Reporting Requirements Elizabeth Rezaizadeh, MPH U.S. Department of Health and Human Services Health Resources and Services Administration Bureau of Health Professions Division of Practitioner Data Banks 1

  2. Presentation Overview Bureau of Health Professions (BHPr) Mission National Practitioner Data Bank Laws, Regulations, Reporting and Querying Healthcare Integrity and Protection Data Bank Laws, Regulations, Reporting and Querying Discussion Scenarios Entity Registration 2

  3. HRSA’s Bureau of Health Professions 3

  4. 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 4 2010 Reorganization

  5. 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. 5

  6. 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.  6

  7. The National Practitioner Data Bank 7

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

  9. 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 9

  10. 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. 10

  11. Section 1921 • Public Law 100-93, Section 5 of the Medicare and Medicaid Patient and Program Protection Act of 1987 (Section 1921 of the Social Security Act) • Section 1921 amended by the Omnibus Budget Reconciliation Act of 1990, Public Law 101-508 • Final regulations codified at 45 CFR Part 60 • Final Rule for Section 1921 published in the Federal Register January 28, 2010 • Implementation of Section 1921 effective March 1, 2010 11

  12. 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. 12

  13. 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 13

  14. NPDB Reporting 14

  15. Overview of NPDB • 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. 15

  16. NPDB: Who Must Report? Malpractice insurers and self-insured organizations State licensing boards for all health care practitioners and entities Hospitals, managed care organizations, other health care entities with formal professional review processHealth care entity provides health care services and follows a formal professional review process to further quality health care. 16

  17. NPDB: Who Must Report? (Continued) Professional societies and memberships with formal professional review process Peer review organizations Excludes Quality Improvement Organizations Private accreditation organizations e.g., Joint Commission, URAC (formerly known as the Utilization Review Accreditation Commission), & National Council for Quality Assurance (NCQA) Drug Enforcement Administration and HHS Office of Inspector General  Based on Memorandum of Understanding with HHS 17

  18. NPDB: Overview of What is Reported Medical malpractice payments Adverse clinical privilege actions taken in the course of professional review activity State licensure actions taken against all health care practitioners and entities Negative actions or findings by peer review organizations and private accreditation organizations Medicare/Medicaid exclusions Adverse registration actions to prescribe controlled medicine taken against health care practitioners 18

  19. Medical Malpractice Payments Each person, entity, or insurer that makes a payment under an insurance policy, self-insurance, or otherwise, for the benefit of a physician, dentist, or other health care practitioner in settlement or judgment against a practitioner for medical malpractice must report this payment to the NPDB. Payments made by federal agencies are also reportable. Employers who insure their employees must report medical malpractice payments. NPDB: What is Reported? 19

  20. What Is Reportable? Reportable medical malpractice payments are: The result of a written complaint orclaim demanding payment Based on provision or failure to provide health care services Based on tort law NPDB: What is Reported? Medical Malpractice Payments • What Is Non-Reportable? • Payments made in situations where there was no written claim or complaint • Payments made to satisfy claims against health care entities that do not identify individual practitioners (Corporate Shield) • Individuals who make a malpractice payment from their own personal funds 20

  21. NPDB: What is Reported? Adverse Actions Overview What is Reportable? • All professional review actions taken which: • Concern physicians or dentists • Are based on professional competence or conduct that adversely affects, or could adversely affect, the health or welfare of a patient • Adversely affect clinical privileges or professional society membership for a period longer than 30 days • Voluntary surrender or restriction of clinical privileges or professional society membership while under, or to avoid, investigation • Summary or emergency suspensions resulting from a professional reviewaction 21 •  Other practitioners MAY be reported

  22. NPDB: What is Reported? Adverse Actions Overview What is Non-Reportable? • Adverse Actions taken without a formal professional review • Actions that do not last longer than 30 days • Actions that do not affect or could adversely affect the health or welfare of a patient 22

  23. NPDB: What is Reported? State Licensure Actions 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). 23

  24. NPDB: What is Reported? State Licensure Actions What is Reportable? • 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) • Summary or emergency suspensions 24

  25. NPDB: What is Reported? State Licensure Actions • What is Reportable? (Continued) • 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 25

  26. NPDB: What is Reported? State Licensure Actions What is Non-Reportable? • 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) 26

  27. NPDB: What is Reported? Peer Review & Private Accreditation Organizations • What is Non-Reportable? • Any action that is not a result of a formal proceeding What is Reportable? • A negative action or finding to sanction a health care practitioner • Any final determination of denial or termination of an accreditation status that indicates a risk to the safety of a patient(s) or quality of health care services. These are taken against health care entities only. *Must be the result of formal proceedings with due process 27

  28. What is Reportable? The NPDB contains reports concerning Medicare/Medicaid exclusions against health care practitioners. NPDB: What is Reported? Medicare/Medicaid Exclusions What is Non-Reportable? OIG and HHS reports which do not concern actions taken against health care practitioners who participate in Medicare/Medicaid programs. 28

  29. What is Reportable? The Drug Enforcement Administration (DEA) reports adverse registration actions on all health care practitioners who dispense controlled substances. NPDB: What is Reported? Adverse Registration Actions What is Non-Reportable? Registration Reports on practitioners who do not have a Federally assigned DEA identification number to dispense medication. 29

  30. Total Number of Reports in NPDB NPDB Reports from September 1, 1990 through December 31, 2010 30

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

  32. NPDB Reports By Practitioner *Reporting entity did not identify Occ/Field of State Licensure Code Data from September 1, 1990 through December 31, 2010 32

  33. NPDB Reports By Practitioner (Continued) Data from September 1, 1990 through December 31, 2010 33

  34. Top 10 Practitioner NPDB Reports by Type NPDB Reports from September 1, 1990 through December 31, 2010 34

  35. Querying the NPDB 35

  36. 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. 36

  37. Querying the NPDB (Continued) Hospitals May Query: At any other time with respect to professional review activities. 37

  38. 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) 38

  39. Querying the NPDB (Continued) The Following May Query the NPDB under Section 1921: • Agencies administering Federal Health Care Programs and their contractors • State agencies administering State Health care programs • State Agencies that license health care entities • Quality Improvement Organizations (QIOs) 39

  40. Querying the NPDB (Continued) The Following May Query the NPDB under Section 1921: • Medicaid Fraud Control Units • U.S. Attorney General and other law enforcement • U.S. Comptroller General 40

  41. Querying the NPDB (Continued) Access to Section 1921 Data ONLY • Entities that are currently allowed to query the NPDB have access to all Section 1921 reports e.g., hospitals, health care entities, State boards • Entities given access to the NPDB through Section 1921 are allowed to query ONLY Section 1921 information  • Practitioners and entities can self-query only • Researchers can use non-identifying data only These entities also have access to Medicare/Medicaid exclusions 41

  42. NPDB Queries NPDB Queries from September 1, 1990 through December 31, 2010 42

  43. 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. 43

  44. 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. 44

  45. Healthcare Integrity and Protection Data Bank (HIPDB)‏ 45

  46. HIPDB Law and Regulations 46

  47. 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. 47

  48. 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. 48

  49. HIPDB Reporting 49

  50. HIPDB: Who Must Report? • Federal and State Agencies • Licensing and certification agencies • Department of Justice, law enforcement agencies, Medicaid Fraud Control Units (MFCUs) • Department of Health and Human Services (e.g., Centers for Medicare & Medicaid Services (CMS), U.S. Food and Drug Administration (FDA), Office of Inspector General) • Agencies that administer or pay for the delivery of health care services (e.g., Dept. of Veterans Affairs) 50

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