What is the National Practitioner Data Bank (NPDB)? (and How Do You Get In & Out?)
The National Practitioner Data Bank (NPDB) operates under the rules established in Title IV of the Health Care Quality Improvement Act of 1986 (HCQIA), and also by Section 1921 of the Social Security Act and Section 1128E of the Social Security Act. It is the repository for a wide variety of negative physician information including medical malpractice payments, a wide variety of adverse actions including resignations while under investigation, summary suspensions and adverse peer review findings. The CFR's governing the NPDB can be viewed here.
National Practitioner Data Bank is at its core – confidential. It is an information clearinghouse that mandates submissions. It collects and discloses certain adverse information related to healthcare practitioners. You get "in" and "out" based upon strict rules and the judgments of others. Once you are in, getting out is like swimming in molasses - backwards!
The Purpose of the NPDB
The data bank was created to improve the quality of healthcare by providing a repository of information that helps organizations and authorities make informed decisions about practitioners’ qualifications and professional conduct. In practice once a physician is in the NPDB his/her career options are severely impacted and a lot of good doctors are caught up in this very broad and sticky net.
Physicians face reporting if they are suspended for more than 30 days and of concern are summary suspensions that may be reversed but can lead to reporting for an extended period (until it is vacated). In the meantime, who sees the report? Criminal convictions, civil lawsuits, resignations while under investigation can all trigger reporting.
Access to the National Practitioner Data Bank is limited to specific entities and individuals under the Healthcare Quality Improvement Act (HCQIA) and the NPDB regulations. The following entities typically have access to the NPDB:
State Licensing Boards: State licensing boards for physicians, dentists, nurses, and other healthcare professionals can request information from the NPDB when considering licensure applications, disciplinary actions, or investigations.
Hospitals and Healthcare Entities: Hospitals, healthcare facilities, and other healthcare entities can query the NPDB when conducting the credentialing and privileging process for healthcare practitioners applying for employment or privileges.
Federal and State Agencies: Certain federal and state agencies, such as the Centers for Medicare & Medicaid Services (CMS), may have access to the NPDB for various purposes, including oversight and monitoring of healthcare programs.
Health Plans: Health insurance plans or managed care organizations may access the NPDB to verify information about healthcare practitioners they contract with.
Medical Malpractice Insurers: Medical malpractice insurance companies can request information from the NPDB as part of their underwriting process for healthcare practitioners.
In other words, not the general public or individual competitors but everyone involved in your career who evaluates you for hire,insurance, privileges etc has access.
A major area concern is malpractice insurer access. Once they see a negative entry will they truly disregard it once the record is cleared? Likewise once an individual sees the entry how do you unring the bell? For these and many other reasons, prompt action is required whenever a summary suspension that can potential reach 30 days, is imposed.
Once you are reported to the National Practitioner Data Bank (NPDB) removal is a complex process and generally not something that a healthcare practitioner can do unilaterally. The NPDB is designed to be a repository of adverse information about healthcare practitioners, and its purpose is to provide a comprehensive record of a practitioner’s history for the protection of the public and to aid healthcare organizations in making informed decisions. You are fighting against that premise so that to quote Mr. Spock from Star Trek, “The interests of the many outweighs the needs of a few.”
THE BASICS OF THE NPDB
The NPDB is the National Practitioner Data Bank (sometimes mistakenly referred to as the National Practitioner Data Base). It is a public restricted but not at all confidential databank medical malpractice payments and certain diverse actions related to a medical (and other) license.
The NPDB Guidebook is a truly useful resource for both doctors and lawyers. Here is the link to the NPDB Guidebook.
California Medical Board Reporting Often Tracks NPDB Reporting
The NPDB reporting is closely tied to Medical Board of California mandated reporting. For example, a report to both the Medical Board of California and the National Practitioner Data Bank is required after a 15 day suspension. California law via Business & Professions Code § 805(b)(2). 805(b)(2), requires the filing of a report with the Medical Board of California within 15 days after a peer review body terminates or revokes “[a] licentiate's membership, staff privileges, or employment ... for a medical disciplinary cause or reason.” (Business & Prof. Code § 805 (b)(2).) The statute refers to such a report as an “805 report”. Parallel to this is the federal law. "A hospital usually is required to report disciplinary actions to the National Practitioner Data Bank, established for the purpose of tracking the activities of incompetent physicians. (42 U.S.C. § 11133(a)). A hospital's decision to deny staff privileges therefore may have the effect of ending the physician's career.” (Mileikowsky v. West Hills Hospital & Medical Center (2009) 45 Cal.4th 1259, 1268) A remember that you can't run from a proceeding as resignation under investigation triggers dual reporting as well.
The NPDB’s website summarizes what is NPDB reported, who is reported (Doctors always) and who has access to the information. Here is their chart.
| Who is Reported? | Who May Query/Request Information? | ||
Title IV | Medical malpractice payers | Medical malpractice payments resulting from a written claim or judgment | Practitioners | Hospitals (required by law) |
State medical and dental boards | Certain adverse licensure actions related to professional competence or conduct | Physicians and dentists | ||
Hospitals | Certain adverse clinical privileges actions related to professional competence or conduct | Physicians and dentists | ||
Professional societies with formal peer review | Certain adverse professional society membership actions related to professional competence or conduct | Physicians and dentists | ||
DEA | DEA controlled-substance registration actions* | Practitioners | ||
OIG | Exclusions from participation in Medicare, Medicaid, and other federal health care programs* |
The Types of Reports filed with the National Practitioner Data Bank
We usually get an NPDB case after there is a filing with the data bank. There are 3 types of reports that can be filed. The first is the Medical Malpractice Payment Report (MMPR) which rather obviously is used to report medical malpractice payments. Note that people will mistakenly refer to the NPDB as the National Practioners (adding the plural possessive) Data Bank, Databank or very commonly National Practitioner Database (base). (They are the same so don't go Googling to see if you are missing something. In fact the last time we Google'd "database" it came up with the same search results as "databank". So Google is smarter than some people.)
A Conviction Report or Judgment Report) is not just reports of health care related crimes (conviction only). It also includes civil judgments. What does or does not qualify is sometimes (but not usually), subject to dispute. These reports apply to federal or state courts. The federal laws are less ambiguous in terms of reporting requirements.
The catch all is called an Adverse Action Report. Anything not covered by the MMPR or judgment/conviction report is filed as an AAR.
Types of Reports & How to Attack a Report
The first step is usually difficult because you are dealing with a hostile entity. But the filing party is responsible for the accuracy of information reported. A factor that is sometimes overlooked is the necessity that the entity keep the information up to date. A criminal case overturned on appeal, a civil judgment also reversed or reduced on appeal may require an update. Certainly disciplinary matters may have additional chapters that require an NPDB update. You can of course file these yourself but the first step is to ask the reporting party to do so.
Initial Report
When we are notified of an “Initial Report” our client has likely just received official NPDB notice of this filing. It is important to remember that an NPDB report notice may also be unofficial notice that the reporting party has provided a copy of the report or made a separate report to the Medical Board.
This “Initial Report" stage is a good time to try to have a “Correction Report” submitted. As it is titled, a Correction Report corrects an error in an earlier report. It can either modify or completely replace the original report. Multiple correction reports are allowed. In terms of credentialing or other instances where outside entities have reviewed the initial filing, you should be aware that the NPDB sends notice of corrections to “inquiring entities” but only those who sought reports within the last 3 years.
The Holy Grail is a Void Report
The best result is a “Void Report” which means it is withdrawn and vanishes. The reporting entity has tremendous power here. They can withdraw the report at any time. This is the most contested and potentially useful area for attorneys to intervene. Yes, we can and do submit MD comments on reports but nothing is better than having the submitting entity withdraw the report because it was:
- Submitted in error.
- The criminal or civil action was set aside on appeal.
- The report was made when it did not fall within the NPDB reporting parameters.
Revision to Action (Can be good or bad)
A “Revision to Action” report is not a withdrawal so it is not a “void report”. It can correct and hopefully mitigate the original report with additional facts. Again, the physician can submit this information but it is more effective if the correction comes from the reporting entity. (And yes, a revision can also worsen matters.) For reasons which are unclear, a Revision to Action Report is not available for Medical Malpractice Payment Reports.
Again, like void reports, revision reports are provided only to entities that made NPDB inquires in the past 3 years. So there can be some legwork to ensure that your files are clear.
If a healthcare practitioner believes that there is an incorrect or inaccurate report in the NPDB, they can take the following steps to address the issue:
Contact the Reporting Entity: The first step is to contact the organization that submitted the report to the NPDB. This might be a hospital, a state licensing board, a federal agency, or another entity that provided the adverse information. The practitioner should attempt to resolve any discrepancies or inaccuracies with the reporting entity directly.
Request a Correction or Deletion: If the reporting entity agrees that the entry is incorrect, they can submit a request to the NPDB to correct or delete the report. The NPDB allows reporting entities to correct or void reports if they determine that the information is erroneous.
Dispute Resolution: If the reporting entity refuses to correct or delete the report, the practitioner can request a dispute resolution process through the NPDB. This process allows for the reconsideration of the report’s accuracy. We recommend using a lawyer for this process and at times a lawyer doctor such as our Dr. Mark Ravis is a "best choice".
This is just the tip of the iceberg and we strongly recommend professional advice. Botched attempts to fix things on your own make later proper attempts more difficult. In other words you can be the Sorcerer's Apprentice and we may not be able to snap our fingers and fix things.
Daniel Horowitz and Dr. Mark Ravis (a lawyer and doctor) defend physicians in NPDB matters. Daniel's office is in Lafayette, California (Contra Costa County). Dr. Ravis is outside Los Angeles (Calabasas). We represent physicians throughout the State of California.
If you have an NPDB reporting issue, call Daniel Horowitz at (925) 291-5388.