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NPDB and HIPDB Statutory Requirements NC AMSS Annual Conference
May 13-15, 2009 Shirley Jones, J.D., M.H.A. U. S. Department of Health and Human Services Health Resources and Services Administration Bureau of Health Professions
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Presentation Overview
Bureau of Health Professions (BHPr) Mission Eligibility and Registration Reporting and Querying Available Data Compliance Activities Proactive Disclosure Service NPDB Expansion: Section 1921
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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 healthcare needs and provide the highest quality of care for all
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Bureau of Health Professions
Office of Shortage Designation Summary of Changes in BHPr Organizational Structure One division and two offices created from former Office of Workforce Evaluation and Quality Assurance (OWEQA) Evaluation and Analysis Branch become Office of Workforce Policy and Performance Management reporting to the Associate Administrator Shortage Designation Branch becomes office reporting to the Associate Administrator Practitioner Data Banks Branch becomes division New Division of Diversity and Interdisciplinary Education established to address cross-cutting issues and comprised of 3 branches. Diversity Branch – includes diversity programs formerly in Division of Health Careers Diversity and Development Geriatrics and Public Health Branch – includes geriatric programs formerly in the Nursing Division and public health programs formerly in the Division of State, Community and Public Health Area Health Education Center Branch – has AHEC program formerly in the Division of State, Community and Public Health New Division of Student Loans and Scholarships established with two branches that were formerly in the Division of Health Careers Diversity and Development Health Education Assistance Loan Branch Campus Based Branch – includes loan and grant programs excluding HEAL 2008 Reorganization
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NPDB-HIPDB Purpose The intent is to protect the public, improve the quality of health care and deter fraud and abuse in the health care system by providing information about past adverse actions of practitioners, providers, or suppliers to authorized health care entities and agencies
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National Practitioner Data Bank
Title IV of Public Law , the Health Care Quality Improvement Act of 1986, as amended Part A: Promotion of Professional Activities Standards for Professional Review Actions Protection for providing information to Professional Review Bodies Part B: Reporting Information National Practitioner Data Bank (NPDB), 45 CFR Part 60
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Eligibility and Registration
Self-certify eligibility to participate in the Data Banks MCO must register for both the NPDB and HIPDB Query: an entity that provides health care services and follows a formal peer review process to further quality health care (NPDB )
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Eligibility and Registration
Report : An entity that makes a medical malpractice payment A State licensing board that takes an adverse action against a physician or dentist A health care entity that takes an adverse clinical privileging action as a results of a professional review Professional society that takes an adverse membership action as a result of a professional review
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NPDB Expansion: Section 1921
A provision of the Social Security Act as amended by Section 5(b) of the Medicare and Medicaid Patient and Program Protection Act of 1987, as amended by the Omnibus Budget Reconciliation Act of 1990 Notice of Proposed Rule Making Published in the Federal Register March 21, 2006 Projected to be Final in the Fourth Quarter 2009
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Healthcare Integrity and Protection Data Bank (HIPDB)
Section 1128E of the Social Security Act as added by Section 221(A) of the Health Insurance Portability and Accountability Act of 1996 and its implementing regulations (45 CFR Part 61); opened October 1999 HIPDB - final adverse actions against healthcare Practitioners Providers, Suppliers, and
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Eligibility and Registration
State Agency Federal Agency Health Plan Broadly defined
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NPDB and HIPDB Administered by Health Resources and Services Administration (HRSA) Funding User fees only
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National Practitioner Data Bank
Reporting
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Who Reports to the NPDB? Medical Malpractice Insurers
Self-Insured Organizations State Funds State Medical and Dental Authorities Adverse Licensure Actions Stayed Actions are not reportable Hospitals Other Health Care Entities with formal peer review
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Who Reports to the NPDB? Professional Societies with formal peer review Federal Agencies Drug Enforcement Agency (DEA) HHS Office of Inspector General Health Resources and Services Administration Indian Health Services Veterans Hospitals Department of Defense Health care entities
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What is Reportable to the NPDB?
Medical Malpractice Payments Adverse Actions (physicians and dentists) Licensure Clinical Privileges Other practitioners may be reported Professional Society Membership Medicare and Medicaid Exclusions DEA Actions
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Medical Malpractice Payments
Any payment, in any amount, made for the benefit of any type of licensed health care practitioner is reportable Payments by self-insured Health care entity Payments by insurance companies Settlements and Judgments Refund of patient fee is reportable if made by an entity (including a Professional Corporation with a solo practitioner) Refund of patient fee is not reportable if made by the practitioner from personal funds
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Who is Reported? A written complaint or claim demanding payment based on a health care practitioner’s provision of or failure to provide health care services Mandatory for all Health Care Practitioners Not just for hands-on treatment Practitioner who performs a referral services, i.e., Department chair Includes licensed Residents or Interns
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MMPR: Procedures Practitioner must be named in both the written complaint or claim demanding monetary payment for damages and the settlement release or final adjudication Any payment amount Report within 30 days of the payment Civil Money Penalty not reporting $11,000 per event
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MMPR: Exceptions “Corporate Shield”̶̶ a payment made as a result of a suit or claim solely against an entity (i.e., hospital, clinic, or group practice) is not reportable Unlicensed medical or dental students A payment made for the benefit of a practitioner from personal funds
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MMPR: Exceptions A payment made to settle a claim or action is not reportable if the defendant practitioner is dismissed from the lawsuit prior to the settlement or judgment If the dismissal resulted from a condition in the settlement or release, then the payment is reportable
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MMPR: Exceptions A payment made at the low end of a High-Low Agreements is not reportable if: Agreement is in place prior to the verdict or decision Fact-finder rules in favor of the defendant and assigns no liability to the defendant practitioner
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Adverse Action Reports
Hospitals, health plans and other eligible health care entities must report: Professional review actions that adversely affect a physician’s or dentist’s clinical privileges for a period of more than 30 days Reporting-mandatory for physicians and dentists
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Adverse Action Reports
Voluntary surrender or restriction of clinical privileges while under investigation for possible professional incompetence or improper conduct Voluntary withdrawal of a renewal application Failure to renew clinical privileges Voluntary withdrawal of an initial application is generally not reportable to the NPDB Reporting is discretionary for other health care practitioners
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Adverse Action Reports
Limitation or reduction of privileges for more than 30 days Proctoring, mentoring Summary or precautionary suspension, abeyance Hospital report within 30 days instead of 15 days?
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AAR: Procedure Adverse action related to professional competence and conduct Report within 30 days of the action date Clinical privileges are reportable on the 31st day Sanctions Loss of immunity protections for 3 years
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Adverse Action Reports
State Licensure Medical and Dental Licensing Boards must report disciplinary actions related to professional competence or conduct Reportable Actions Revocation, Suspension, Censure, Reprimand, Probation, and Surrender Sanction Licensing Board Designation of another qualified entity to report
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Adverse Action Reports
Professional Society Membership Must report professional review actions that relate to professional competence or conduct that adversely affects the practitioner’s membership Applies to: Physicians, Dentists, and Other health care practitioners
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What is in the NPDB? 12/31/2008
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NPDB: Number of Reports By Practitioner Type
12/31/2008
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NPDB: Number of Reports By Practitioner Type
12/31/2008 * Reporting entity did not identify Occ/Field of State Licensure code
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NPDB Expanded Section 1921
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Major Reports Added by Section 1921
Adverse licensure actions taken against all health care practitioners, including physicians and dentists Adds the same type of licensure actions currently reported to the HIPDB Adverse actions or findings by private accrediting organizations Adverse actions or findings by non-QIO peer review organizations
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Section 1921 Access Entities that are currently allowed to query the NPDB will have access to Section 1921 reports Entities given access to the NPDB through Section 1921 will be allowed to query ONLY Section 1921 reports
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Healthcare Integrity and Protection Data Bank
Reporting
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Who Reports to the HIPDB?
Federal Government Agencies State Government Agencies Health Plans
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What Practitioners are Reported
Health Care Related Actions Against Licensed Practitioners Physicians Dentists Allied Health Professionals Providers Hospitals Skilled nursing facilities Suppliers DMEs
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What Actions are Reportable?
Licensure Actions Health care related actions against physicians and dentists that are not related to professional competence and conduct Health care related actions against all others licensed health care practitioners Medicare and Medicaid Exclusions Federal Health Care Programs State Health Care Programs
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What Actions are Reportable?
Health Care Related Actions Criminal Convictions, or Civil Judgments Other Adjudicated Actions Formal or official final action Availability of a due process mechanism Acts or omissions that affect or could affect the payment, provision, or delivery of a health care service or item Temporary actions are not reportable Summary or emergency actions
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What is in the HIPDB? Practitioner Reports
12/31/2008
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What is in the HIPDB? Provider and Supplier Reports
12/31/2008
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HIPDB: Number of Reports By Practitioner Type
12/31/2008
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HIPDB: Number of Reports By Practitioner Type
12/31/2008
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NPDB and HIPDB Physician Reports
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NPDB-HIPDB: Physician Reports
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Healthcare Integrity and Protection Data Bank
Access to Information
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Who has Access to the HIPDB?
Federal Government Agencies State Government Agencies Health Plans Practitioners, Providers, and Suppliers Self-query only Researchers Non-identifiable statistical information
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HIPDB Queriers 2008 Total Queries: 1,184,209
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National Practitioner Data Bank
Access to Information
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Who can Query the NPDB? Hospitals– Mandatory
Initial application for medical staff appointment or clinical privileges (courtesy or otherwise) Physicians, dentists, and other health care practitioners Every two years, thereafter Request to add or expand existing privileges Application for temporary privileges Other Health Care Entities Formal peer review Employ or Contract
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Who can Query the NPDB? State Medical and Dental Licensing Authorities
Professional Competence and Conduct related Actions Professional Societies with formal peer review Plaintiff’s Attorney Limited Access Practitioners Self-query Researchers Non-identifiable statistical information
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NPDB Queriers 2008 Total Queries: 4,122,544
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NPDB-HIPDB: Proactive Disclosure Services
Continuous Querying
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Proactive Disclosure Services
Prototype No More—Here to Stay!! A subscription service that notifies the subscriber of new information on any of their enrolled practitioners within 24 hours of the Data Banks receipt of the information Average querier receives a new Data Bank report in 302 days
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Endorsements The Joint Commission NCQA
Commission on Accreditation of Rehabilitation Facilities (CARF) The Centers for Medicare and Medicaid Services (CMS)
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Proactive Disclosure Service
VS. The Traditional Query Method
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Traditional service - Requires users to logon to query the Data Banks on their practitioners.
PDS Prototype - Provides continuous monitoring, 24 hours a day, 7 days a week, 365 days a year on enrolled practitioners.
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Traditional service – An average of 302 days will lapse between receipt of a report and the disclosure of information in response to a query. PDS Prototype – Will notify subscribers of a report on their enrolled practitioners within 24 hours of receipt by the Data Banks.
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PDS Provides evidence of a query to meet accreditation continuous monitoring standards
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PDS Allows you to manage your subject database using your own practitioner identifiers
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PDS Identifies potential duplicate subject enrollments
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Traditional service – Does not notify you that a practitioner may be a duplicate entry when submitting multiple names in one query. Names that are added into the subject data base are checked for duplicate entries. PDS Prototype – Provides a message that a name may be a duplicate submission.
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PDS Enrollment Process
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PDS Work Flow
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PDS Work Flow
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PDS Work Flow
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PDS Work Flow (3.25 PEPY)
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PDS Work Flow
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Post Enrollment
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PDS Work Flow
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PDS Work Flow
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PDS Work Flow
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PDS Enrollment Enrollment Confirmation:
An enrollment confirmation confirms that a practitioner is enrolled in the PDS May be used to demonstrate compliance with accreditation standards Enrollment confirmations include Subject information PDS enrollment dates, and Enrollment status
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Enrollment Confirmation
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Enrollment Confirmation (Individual)
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Enrollment Confirmation (continued)
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PDS Subject List
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Report Notification Notifications are sent for: New Reports
Corrections Revisions Voids Subject Statements Disputed Status/Secretarial Review
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PDS Renewal A PDS subscriber receives an notice two months in advance to renew practitioners A reminder is sent monthly until the subscribing entity renews the practitioners A grace period of one month is provided
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Renewal
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Renewal
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Renewal
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PDS Cancellation An enrollment must be cancelled when a practitioner leaves your staff A cancelled enrollment cannot be reactivated However, enrollment confirmation is available for cancelled enrollments Canceled enrollment data is retained for four years
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Cancellation
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Cancellation
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Cancellation
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Cancellation
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Cancellation
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Cancellation
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Cancellation
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Cancellation
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Confirmation Form PDS Subject List
Use in Accreditation Confirmation Form PDS Subject List
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Enrollment Confirmation
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Enrollment Confirmation (Individual)
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Enrollment Confirmation (continued)
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PDS Subject List
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NPDB - HIPDB Report Disputes
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The Dispute Process The reporting entity, only, may make changes to a report The reporting entity is responsible for the accuracy of the information it reports The subject of a report may add a statement to the report at any time The subject statement becomes a part of the specific report
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Secretarial Review If the reporting entity refuses to change a disputed report the subject may request a Secretarial Review Scope of a Secretarial Review Can not review the merits of the action Procedural review Limited to A review for accuracy of factual information and Ensure that the action was reportable
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Compliance Activities
NPDB - HIPDB Compliance Activities
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Current Priorities Timely Reporting Under Reporting Under Querying
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Overall Timeliness Percent Timely 51.1% 40.1% 35.7% 30.1%
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Compliance Activities
NPDB and HIPDB Regulations mandate reporting within 30 days of the date of the final action Provide Notice of non-compliance with reporting requirements State Licensure Authorities Hospitals Compare NPDB payment reports to the NAIC summary payment reports (Supplement A to Schedule T) Monitor the eligibility of Data Bank Registrants Monitor for violations of Confidentiality Rules
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Reference Information
Web Site - NPDB and HIPDB Guidebooks Interactive Training Brochures and Fact Sheets Statistics Annual Reports Instructions for Reporting and Querying Customer Service Center (1-800-SOS-NPDB)
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Any Questions??
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Contact Information Shirley A. Jones, JD, MHA Senior Policy Analyst Health Resources and Services Administration Bureau of Health Professions Division of Practitioner Data Banks (301)
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THANK YOU!!
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