Who Can Query the National Practitioner Data Bank?

Briefing Document: Who Can Query the National Practitioner Data Bank (NPDB)?

Date: October 26, 2023 Source: Excerpts from "Who Can Query the National Practitioner Data Bank?" Purpose: This briefing document provides a detailed review of the main themes and most important ideas or facts regarding which entities and individuals are authorized to query the National Practitioner Data Bank (NPDB), the types of information they can access, and the conditions under which they may query. Key Themes:

• Restricted Access: Access to the NPDB is strictly controlled and limited to specific authorized entities and individuals for defined purposes.
• Mandatory Queries: Federal law mandates certain entities, particularly hospitals, to query the NPDB under specific circumstances.
• Purpose-Driven Access: Most authorized entities are only permitted to query the NPDB for specific reasons related to professional review, employment/affiliation decisions, program integrity, or law enforcement.
• Varying Information Access: The type of information available to a querier depends on their registration with the NPDB and their category of authorization.
• Consequences of Failure to Query: Failure to comply with mandatory query requirements can have significant legal implications, including potentially granting plaintiff's attorneys access to NPDB information. Most Important Ideas and Facts: 1. Who Can Query the NPDB? The source details a variety of entities and individuals authorized to query the NPDB. These include:
• Hospitals: Mandated by federal law to query.
• Other Health Care Entities: May query under specific conditions.
• Agencies Administering Government Health Care Programs: Including federal and state agencies and private entities under contract.
• Federal Law Enforcement Officials and Agencies: Authorized for program integrity and safety purposes.
• Federal Licensing and Certification Agencies: For health care practitioners, providers, or suppliers.
• Health Plans: For determining fitness and program integrity.
• Professional Societies: When entering relationships or engaging in professional review.
• Quality Improvement Organizations: For fitness, safety, and program integrity.
• State Agencies Administering or Supervising State Health Care Programs: Similar to federal program administrators.
• State Law Enforcement Agencies and State Medicaid Fraud Control Units: For fitness, safety, and program integrity.
• State Licensing and Certification Agencies: For health care practitioners, providers, or suppliers.
• State Medical Boards of Examiners or Other State Authorities that License Health Care Practitioners: May query at any time.
• Health Care Practitioners, Entities, Providers, and Suppliers: May perform a Self-Query.
• Plaintiff's Attorneys/Plaintiffs: Under limited conditions in medical malpractice cases against a hospital. Quote: "When an entity queries the NPDB, the NPDB determines how the entity is registered with the NPDB before releasing information, and it releases only lawfully permitted information based on the entity's registration." 2. Mandatory Queries for Hospitals: Hospitals have the most stringent requirements for querying the NPDB under federal law. They must query:
• When a physician, dentist, or other health care practitioner applies for medical staff appointment or clinical privileges (including temporary privileges).
• Every two years (biennially) for all practitioners on their medical staff or holding clinical privileges.
• Each time a practitioner wishes to add to or expand existing privileges or applies for temporary privileges.
• Each time a locum tenens practitioner applies for temporary privileges.
• On residents and interns when they are appointed to the medical staff or granted privileges outside of their formal education program (e.g., "moonlighting"). Quote: "Hospitals are the only health care entities mandated by federal law to query the NPDB." 3. Permitted (Non-Mandatory) Queries: Beyond the mandatory requirements, hospitals and other authorized entities may query the NPDB under specific circumstances:
• Hospitals may query at any time they deem necessary for professional review activity or for employment/affiliation decisions.
• Other health care entities generally may query when entering employment/affiliation relationships, when practitioners apply for privileges, or during professional review activity.
• Agencies, law enforcement, licensing bodies, health plans, and quality improvement organizations may query for determining fitness, protecting health and safety, or protecting fiscal integrity of programs.
• Professional societies may query for employment/affiliation (membership) or professional review activity.
• State medical boards and other state licensing authorities may query at any time. Quote: "Generally, hospitals may query when the hospital is entering into an employment or affiliation relationship with the health care provider, or when the hospital is engaging in professional review activity." 4. Information Available to Queriers: The type of information released by the NPDB varies depending on the querier's category. Common types of information include:
• Medical malpractice payment information.
• Licensure actions by boards and states.
• Federal licensing and certification actions.
• Adverse actions taken by health care entities against clinical privileges.
• Negative actions or findings by peer review organizations or accreditation entities.
• Health care-related criminal convictions and civil judgments (availability may vary based on reporting source for some entities).
• Exclusions from participating in federal or state health care programs (availability may vary based on reporting source for some entities).
• Other health care-related adjudicated actions or decisions (availability may vary based on reporting source for some entities). Note: Some entities, such as other health care entities, professional societies, and quality improvement organizations, are not authorized to receive certain adverse actions reported under Section 1921, including exclusions from state health care programs, state court criminal convictions and civil judgments, and other state adjudicated actions. Quote: "Hospitals receive the following types of information in response to their queries: [list of information types]" (This quote is followed by a list for each type of querier). 5. Consequences of Failure to Query: Failing to perform a mandatory query on a practitioner can have serious repercussions for a hospital. Quote: "If a hospital does not query on a practitioner when required, the hospital is presumed to be aware of the information reported to the NPDB concerning the practitioner." Furthermore, a hospital's failure to query can grant access to NPDB information for plaintiff's attorneys or self-representing plaintiffs in medical malpractice actions against the hospital, provided specific conditions are met. Quote: "A hospital's failure to query on a practitioner may give a plaintiff's attorney or plaintiff representing himself or herself access to NPDB information on that practitioner for use in litigation against the hospital." 6. Attorney Access: Access to NPDB information for plaintiff's attorneys or plaintiffs representing themselves is very limited and requires specific conditions to be met in a medical malpractice action against a hospital:
• A medical malpractice action must be filed against a hospital.
• The practitioner must be named in the action.
• Evidence must be submitted to the Department of Health and Human Services demonstrating the hospital's failure to submit a mandatory query regarding the named practitioner. This evidence must be obtained through discovery from the hospital, not the NPDB. Quote: "A plaintiff's attorney or a plaintiff representing himself or herself is permitted to obtain certain information from the NPDB under the following limited conditions: [list of conditions]" Conclusion: The NPDB serves as a crucial database for tracking adverse actions against health care practitioners and entities. Access is carefully regulated to ensure the information is used for appropriate purposes related to patient safety, program integrity, and professional review. Hospitals bear a significant responsibility for mandatory querying, and failure to comply can have severe consequences. While access is generally restricted, specific categories of entities and individuals, including under limited circumstances plaintiff's attorneys, are authorized to query based on their roles and specific needs for the information. Understanding the parameters of who can query and under what conditions is essential for compliance and effective utilization of the NPDB.