Florida Association of Nurse PractitionersAugust 7, 2015

Margarita Morales, MS

U.S. Department of Health and Human Services

Health Resources and Services AdministrationBureau of Health Workforce

Division of Practitioner Data Bank

• National Practitioner Data Bank (NPDB) General Provisions

• Reporting and Querying Detailso Reporting and Querying Overviewo Hospital Queryingo Hospital Reportingo Report Subjectso Potential Hospital Sanctionso Continuous Query

• NPDB Compliance • NPDB Guidebook• Resources• Contact Information

Presentation Overview

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General Provisions

Purpose Created under three

statutes to meet several needs:• Flagging system for

effective credential reviews

• Protection against unfit practitioners

• Deter fraud and abuse in the health care system 3

Merger Goal: Eliminate duplication between the NPDB and HIPDB

General Provisions

• The 3 statutes-- Title IV of Public Law 99-660, Section 1921 of the Social Security Act, and Section 1128E of the Social Security Act --remain in effect

• ONE data bank

• ONE set of regulations governing the NPDB’s operations

4

General Provisions

Types of Information Collected• Medical malpractice judgments, settlements

• Adverse licensing, certification actions

• Clinical privileges actions

• Health plan contract terminations

• Professional society membership actions

• Negative actions/findings from private

accreditation organizations and peer review

organizations

• Government administrative actions, e.g.,

exclusions from programs

• Civil & criminal health care-related judgments5

General Provisions

Types of Transactions• Reporting (no charge)

• Querying (by hospitals and health careorganizations)

o $3 for a one-year continuous query subscription

o $3 for a one-time query o Fees lowered October 1, 2014

• Self-Query (by an individual or organization)

o $5o Fee lowered October 1, 2014

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General Provisions

Recovering Costs• By law, the NPDB must recover

the full cost of operations. It does so by collecting fees for each query.

Confidentiality• Information reported to the

NPDB is confidential, not available to the general public, and may not be disclosed except as provided by law.

• Penalty up to $11,000 per confidentiality violation. 7

General Provisions

Civil Liability Protection• Immunity provisions in Title IV,

Section 1921, and Section 1128E protect individuals, entities, and their authorized agents from being held liable in civil actions for reports made to the NPDB unless they have actual knowledge that the information in the report is false.

• Health care entity professional review bodies, their members, and their agents are immune from civil liability in most cases.

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Reporting and Querying

Details

9

Reporting and Querying Overview

ENTITY TYPE REPORT QUERYHospitalsHealth plansOther health care entities with formal peer review State agencies that license and certify health care practitioners and entities, including boards of medical and dental examinersState agencies administering or supervising state health care programsState law enforcement or fraud enforcement agencies (including state Medicaid fraud control units and state prosecutors)Federal licensing and certification agenciesAgencies administering federal health care programs, including private entities administering such programs under contractFederal law enforcement officials and agencies (including Drug Enforcement Agency, HHS Office of Inspector General, and federal prosecutors)

Medical malpractice payersProfessional societies with formal peer reviewPeer review organizations (excluding quality improvement organizations)Private accreditation organizationsQuality improvement organizationsIndividual practitioners, providers, and suppliers (self-query only)

10Required Not Authorized Optional

Hospital Querying

May query on: Health care practitioners with whom the hospital has entered (or maybe entering) employment or affiliation relationships

Must query on: Health care practitioners when practitioners apply for staff appointments (courtesy or otherwise) or clinical privileges (including temporary privileges); every two years for practitioners on staff or with clinical privileges

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Hospital Querying

• Centralized Credentialing

• Querying Through an Authorized Agent

• Delegated Credentialing

• Continuous Query

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Hospital Reporting

Overview

• Must report on: Physicians and dentistso Adverse clinical privileges actions >30 days related to

professional competence or conduct

• May report on: Other practitionerso Adverse clinical privileges actions >30 days related to

professional competence or conduct

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Hospital Reporting

• Denials, reductions, and restrictions of privileges

• Withdrawals and Non-renewals

• Summary suspensions• Report forwarding to

State Licensing Boards• Investigations

o “While under investigation or in return for not conducting such an investigation”

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Potential Hospital Sanctions

Failure to Report

Loss of immunity protections provided for professional review activities that occur during the 3-year period and organization name published in the Federal Register

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Failure to Query

Plaintiff is allowed access to NPDB information on that practitioner for use in litigation against the hospital.

Physicians95,500

Dentists19,000

PhysicianAssistants

3,500

Advanced PracticeNurses5,000

Chiropractors6,500

Podiatrist2,500

Optometrist/Optician

1,500

Registered Nurses128,000

Licensed Practical/Vocational Nurses

82,000

Social Workers4,500

Psychologist2,500

Other BehavioralHealth7,500

Pharmacists/PharmacyTechnicians

27,000

Emergency MedicalTechnician

5,500

Nurse Aides/Nursing Assistants/Home Health Aides

55,500

Physical/Occupational/Respiratory/Massage Therapists/Assistants

14,500 Other Technologist/

Technician1,000

Other Individual Subjects21,000

Total: ~482,500 Reports

Report Subjects

Approximate Number of New NPDB Reports Submitted On Individual Subjects From 2010 – 2014 by Profession

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Reports by Profession

36.92%

15.35%9.63%8.21%

7.26%

5.28%2.84%

2.83%2.75%

2.67%1.94%

1.07%

0.72%

0.61% 0.60%

0.60%0.4%

0.34%

NPDB Reports by ProfessionPhysician-MD: 36.9%, N=405,685

Registered Nurse: 15.4%, N=168,641

Licensed Practical Nurse: 9.6%, N=105,774

Nursing Para-Professionals: 8.2%, N=90,236

Dentist: 7.3%, N=79,736

Other: 5.3%, N=58,058

Physician-DO: 2.8%, N=31,223

Therapists and Counselors: 2.8%, N=31,126

Pharmacist: 2.8%, N=30,198

Technicians and Assistants: 2.7%, N=29384

Chiropractor: 1.9%, N=21,310

Podiatrist: 1.1%, N=11,762

Social Worker: 0.7%, N=7,889

Physician Assistant: 0.6%, N=6.707

Adv. Practice Nurse: 0.6%, N=6,559

Psychologist: 0.6%, N=6,580

Dental Asst/Hygienists: 0.4%, N=4,116

Ocularist/Optician/Optometrist: 0.3%, N=3.709

NPDB Reports from September 1, 1990 through December 31, 2013 (2014Q2 IAF file)

Continuous Query

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Continuous Query

Purpose• A subscription service that notifies

subscribers of new information on any of their enrolled practitioners within one business day of the NPDB’s receipt of the information

• Designed and developed to help meet new accreditation standards that require ongoing monitoring of practitioners

• Since 2007, health care providers have enrolled more than 1.85 million practitioners

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Continuous Query

With One-Time Query

• An average of 320 days pass between receipt of a report and disclosure of the report in response to a query.

• Re-credentialing means re-querying practitioners and reviewing all results to identify new information – a tremendous amount of effort for large organizations.

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With Continuous Query

• Service notifies subscribers of a report on their enrolled practitioners within one business day of receipt by the NPDB

• By handling new reports as they are disclosed, subscriber organizations are always up to date. Subscribers can deal only with events that need attention, immediately resolving issues

Continuous Query

Using Continuous Query

• Requires the same practitioner information

• Subscribers continue using their subject databases

• Fee: $3.00 per enrollee per year

• No separate query fee

• Upon enrollment, receive the same report information as a one-time query response

• Continuously queries the NPDB and notifies subscribers of any new reports

• No need to re-query for reappointments or temporary privileges extensions 21

Continuous Query

Endorsements• The Joint Commission • National Committee for Quality Assurance

(NCQA)• Commission on Accreditation of Rehabilitation

Facilities (CARF)• Utilization Review Accreditation Commission

(URAC)• Centers for Medicare & Medicaid Services (CMS)

Using Continuous Query helps meet obligations imposed by the Health Care Quality Improvement Act of 1986 (HCQIA). 22

NPDB Compliance

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• To date, NPDB compliance activities have

focused primarily on licensing boards

• Licensing board process updated in January

2015

• Currently shifting attention to other areas,

in addition to ongoing licensing board

efforts:o Medical malpracticeo Health planso Judgments/Convictionso Hospitals

• Increased focus on improving NPDB

registration data and overall data integrity 24

NPDB Compliance

State Board Adverse Action Comparison Impact (As of Dec. 2014)

- New Reports are those submitted with effective dates during the time period being reviewed (2010-2012) and concurrent with the compliance effort

- New Reports Disclosed represents the number of New Reports that have been disclosed as of December 2014 to queriers

- Total Disclosures from New Reports represents the number of times the New Reports have been disclosed as of December 2014 to queriers

NPDB Compliance

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

New Reports New Reports Disclosed Total Disclosures fromNew Reports

635 369

1,485

6,078

571

1,781

6,713

940

3,266

Other Professions

Physicians

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2013-2014 State Board Attestation

Results (as of Dec. 2014)

2010-2012 State Board Adverse Action Comparison Results (as of

Dec. 2014)

- Attestation occurs for each board every two years at registration renewal

- Profession refers to state/profession combinations- Could Not Attest indicates a statement by the board

that it could not attest that all reports have accurately been submitted

- Failed to Attest indicates the board failed to provide a response for the profession

- Review completed for the 12 most queried professions (i.e., nurses, pharmacists, physician assistants, podiatrists, psychologists, social workers, physicians, dentists, chiropractors, optometrists, physical therapists, and behavioral health professionals) in each state. Allied health professions (e.g., pharmacy technicians, nursing assistants, dental hygienists) were also included.

NPDB Compliance

Professions Compliant96.82%

Professions Under Review1.21%

Professions Working Towards Compliance

0.95% Professions Non-Compliant

1.02%

Total Professions Reviewed = 1,574

Professions Attested83.14%

Professions Could Not Attest8.00%

Professions Failed to Attest8.86%

Total Attestation Professions = 1,050

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NPDB ReportsFlorida APRN vs.

Physician

NPDB Research Statistics:

http://www.npdb.hrsa.gov/resources/npdbstats/npdbStatistics.jsp 27

Adverse Action by Report Type - Florida APRN

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Stahl, Anne L. National Practitioner Data Bank. Location by Payment Year. Generated using the Data Analysis Tool at http://www.npdb.hrsa.gov/analysistool. Jun 05, 2015. Data source: National Practitioner Data Bank (2013): Adverse Action and Medical

Malpractice Reports (1990-2013)."

Adverse Action & Malpractice Payment- Florida

APRN

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Stahl, Anne L. National Practitioner Data Bank. Location by Payment Year. Generated using the Data Analysis Tool at http://www.npdb.hrsa.gov/analysistool. Jun 05, 2015. Data source: National Practitioner Data Bank (2013): Adverse Action and Medical

Malpractice Reports (1990-2013)."

Malpractice Payment Totals

Florida APRN

Stahl, Anne L. National Practitioner Data Bank. Location by Payment Year. Generated using the Data Analysis Tool at http://www.npdb.hrsa.gov/analysistool. Jun 05, 2015. Data source: National Practitioner Data Bank (2013): Adverse Action and Medical

Malpractice Reports (1990-2013)."

AttestationRequired at NPDB registration renewal for all boards

licensing or certifying health care professions.Attestation has three parts:• Review and update agency’s profile to reflect

changes over the last two year period.• Profession Verification: agencies review,

verify, and update the list of professions they currently regulate.

• Certification: all agencies attest to their compliance with NPDB reporting requirements for each of their regulated professions.    

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NPDB Compliance

Audit of Board Actions• One-to-one audit of all professions

representing 80% of query volumeo Physicians (MD and DO)o Dentistso Physician Assistantso Advanced Practice Nurseso Registered Nurseso Social Workers

• Random selection of all other professions • Sample drawn every two years• Any other profession or board may be

audited at the discretion of HRSA32

NPDB Compliance

NPDB Guidebook

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3434

35 35

What the new Guidebook does:• Blends Healthcare Integrity and

Protection Data Bank and NPDB to reflect new combined regulations

• Adds Section 1921• Provides policy clarificationWhat the new Guidebook does NOT do:• Make revisions that require

legislative or regulatory changes

• Accept or address every recommendation made by commenters.

Key Changes

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• Eligible entitiesoDefinition of “Other

Health Care Entity”oRegistration requirements

(use of DBIDs, User IDs)• Subjects of Reports

oDefinitions of health care practitioners, providers, and suppliers

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Key Changes

• QueriesoCentralized credentialingoDelegated credentialingoClinical vs. non-clinical privileges

• Reportso Submitting reports- Corrections vs. revisions - Appeals

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Key Changes

• Reporting Medical Malpractice Paymentso Oral vs. written claims o Identifying practitioners

• Reporting Adverse Clinical Privileges Actionso Summary Suspensionso Proctors

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Key Changes

o Investigations

Definition of term is not controlled by entity’s bylaws.

Routine review of a practitioner is not an investigation.

Focus on a particular practitioner.

Precursor to professional review action.

Ongoing until decision-making authority takes final action.

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Key Changes

• Reporting Adverse Professional Society Membership Actionso Expert witness testimony

• Other adjudicated actionso Taken in conjunction with clinical

privileges actions

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Key Changes

• Reporting Licensure and Certification Actions o Administrative fineso Summary/Emergency suspensionso Stayed actionso Denials o Withdrawals, and failure to renew while

under investigationo Voluntary surrenders

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Key Changes

Help When You Need It www.npdb.hrsa.gov

Resources

• FAQs, Brochures, and Fact Sheets• NPDB Guidebook• Recorded Webinars• Instructions for Reporting and Querying• Regulations• Statistical Data• Research Tools• NPDB newsletter• NPDB Customer Service Center • 800-767-6732 • Email help@npdb.hrsa.gov

NPDB Compliance Tip Line

301-945-9601

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Questions

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Contact Information

Margarita Morales, MSDivision of Practitioner Data BankBureau of Health WorkforceHealth Resources and Services AdministrationU.S. Department of Health and Human Services

Telephone: 301-443-2300Email: mmorales@hrsa.gov

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Q & A Game

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Question 1:• If a State board that regulates NPs

issues a cease and desist order against a person who is not a NP but who is practicing as one, is the issuance of the cease and desist order reportable to the NPDB?

Subjects of Reports

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Answer 1:Yes. In this example, the State regulates the practice of NPs and prohibits individuals from practicing as NPs – even if they do not refer to themselves as NPs – without being licensed by the board. NPDB regulations require the reporting not only of individuals who are licensed, but also those who hold themselves out to be so licensed. Therefore, the cease and desist order issued by the board would be reportable.

Subjects of Reports

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Question 2:• Mercury Hospital’s peer review panel

restricts a nurse practitioner’s clinical privileges for 30 days due to concerns about his ability to perform certain procedures safely. Is this reportable?

Subjects of Reports

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Answer 2:It depends. Clinical privilege actions/panel membership actions taken against a practitioner other than a physician or dentist may be reported. However, to be reportable, the action must adversely affect the practitioner’s clinical privileges for more than 30 days.

Subjects of Reports

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Hospital’s Querying RequirementQuestion 3:• Under what conditions are hospitals

required to query every 2 years on courtesy staff who are afforded only non-clinical professional privileges?

Queries

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Hospital’s Querying RequirementAnswer 3:Hospitals are required to query on courtesy staff considered part of the medical staff, even if afforded only non-clinical professional courtesies such as use of the medical library and continuing education facilities. If a hospital extends non-clinical practice courtesies without first appointing practitioners to a medical staff category, querying is not required on those practitioners.

Queries

52

Hospital’s Querying RequirementQuestion 4:• An advanced practice nurse (APRN) is

applying for a position at a hospital. Does the hospital have to query the NPDB on the nurse?

Queries

53

Hospital’s Querying RequirementAnswer 4:It depends. If the hospital considers the position the APRN is applying for to be on the hospital’s medical staff, or if the APRN will hold clinical privileges at the hospital, the hospital must query on the APRN when the APRN applies and biennially thereafter while the APRN is on staff or holds privileges. If the hospital does not consider the position to be on the medical staff or if the APRN will not hold clinical privileges, the hospital is not required to query on the APRN. It may do so if it desires, however.

Queries

54

Submitting Reports: Correction vs. RevisionQuestion 5:• If an entity changes the penalty it

imposes or reconsiders the grounds upon which it took an action, should a correction or revision be filed?

Reports

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Submitting Reports: Correction vs. RevisionAnswer 5:If an entity subsequently changed the penalty it imposed, or if it reconsidered the grounds on which it took an action, but the original report correctly described the penalty or grounds at the time the original report was filed, then a Revision-to-Action Report, not a Correction Report, should be filed.

Reports

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Medical Malpractice PaymentsQuestion 6:• Following an unsuccessful course of

treatment, a patient and a practitioner enter into a State-sponsored voluntary series of discussions in an attempt to settle their disagreement before resorting to litigation. The discussions lead to the practitioner’s insurance company making a money payment to the patient to settle the dispute. Should this money payment be reported to the NPDB?

Reports

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Medical Malpractice PaymentsAnswer 6:It depends. If, during the course of discussions, the patient made a written complaint or written claim demanding a monetary payment for damages, the payment must be reported. If the complaint or claim for damages was never put in writing, the payment is not reportable.

Reports

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Medical Malpractice PaymentsQuestion 7:• If an individual practitioner is not

named, identified, or described in a medical malpractice claim or complaint, but the facility or practitioner group is named, should the payment be reported?

Reports

59

Medical Malpractice PaymentsAnswer 7:No, with one exception. If the named defendant is a sole practitioner identified as a “professional corporation,” a payment made for the professional corporation must be reported for the practitioner.

Reports

60

Clinical Privileges ActionsQuestion 8:• Based on assessment of professional

competence, a proctor is assigned to watch a NPs procedures for a period of more than 30 days, and the proctor needs to be present or grant approval before medical care is provided by the practitioner. Is this reportable to the NPDB?

Reports

61

Clinical Privileges ActionsAnswer 8:It depends. Clinical privilege actions/panel membership actions taken against a practitioner other than a physician or dentist may be reported. However, to be reportable, the action must adversely affect the practitioner’s clinical privileges for more than 30 days

Reports

62

Clinical Privileges ActionsQuestion 9:• A NP who applied for clinical

privileges does not meet a health plan’s threshold criteria for the privileges and withdraws the application. Is this reportable to the NPDB?

Reports

63

Clinical Privileges ActionsAnswer 9:No. A health plan should not report the withdrawal of a NPs application for clinical privileges when the NP fails to meet the health plan’s threshold requirements.

Reports

64

Clinical Privileges ActionsQuestion 10:• A NP applied for a medical staff

appointment at a hospital but then withdrew the application before a final decision was made by the hospital’s governing body. The NP was not being specifically investigated by the hospital. Should the withdrawal of the application be reported to the NPDB?

Reports

65

Clinical Privileges ActionsAnswer 10:No. Absent a particular investigation, the voluntary withdrawal of an application for medical staff appointment or clinical privileges should not be reported to the NPDB.

Reports

66

Clinical Privileges ActionsQuestion 11:• A physician applied to a hospital for clinical

privileges to perform cardiac procedures. The hospital requires that such applications be granted only if the applying physician has performed 50 cardiac procedures in the previous year. The applying physician has performed only 40 such procedures. The hospital denies the application based solely on the physician not having met its 50-procedure requirement. Should this denial be reported to the NPDB?

Reports

67

Clinical Privileges ActionsAnswer 11:No. A denial of clinical privileges that occurs solely because a practitioner does not meet a health care institution’s established threshold criteria for that particular privilege should not be reported to the NPDB. Such denials are not considered to be the result of a professional review action relating to the practitioner’s professional competence or professional conduct but, rather, are considered to be decisions based on eligibility that are not reportable.

Reports

68

Clinical Privileges ActionsQuestion 12:• When a NP surrenders medical staff

privileges due to personal reasons, infirmity, or retirement, and such a surrender did not occur in order to avoid an investigation or during an investigation, should it be reported to the NPDB?

Reports

69

Clinical Privileges ActionsAnswer 12:No. The surrender not should not be reported to the NPDB because the NP did not surrender her clinical privileges while under investigation by a health care entity relating to possible professional incompetence or improper professional conduct, or in return for not conducting such an investigation. However, if an investigation was under way when the NP surrendered her privileges, even if the NP was not aware of the investigation, the surrender would have to be reported even if the NP claimed she surrendered the privileges for unrelated personal reasons.

Reports

70

Clinical Privileges ActionsQuestion 13:• A health plan terminated a NPs

contract for causes relating to poor patient care, which in turn resulted in the loss of the practitioner’s network participation. Should this be reported to the NPDB using one or two reports?

Reports

71

Clinical Privileges ActionsAnswer 13:Depending on the circumstances, the health care entity may be required to submit two different reports. The loss of the practitioner’s network participation that resulted from the termination of the contract for reasons relating to professional competence or professional conduct must be reported as a clinical privileges action only if it is considered to be a professional review action by the health care entity.

Reports

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Clinical Privileges ActionsQuestion 14:• A preferred provider organization

(PPO) investigated a member NP after receiving quality of care complaints from several plan participants. The NP was unaware of the investigation, but, during the investigation, he relinquished his panel membership for personal reasons. Is this reportable?

Reports

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Clinical Privileges ActionsAnswer 14:Yes. A health care entity must report a NPs surrender of panel membership (a form of clinical privileges) while under investigation. The reporting entity should be able to produce evidence that an investigation was initiated prior to the surrender, and the NPs awareness of the investigation is immaterial. In addition, in this situation, any termination of the NPs contract with the PPO must be reported to the NPDB separately if the action meets the definition of an “other adjudicated action or decision.”

Reports

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