New Rules Increase Reporting Obligations and Access to the National Practitioner Data Bank

Under new rules set to become effective March 1, 2010, states will be required to report to the National Practitioner Data Bank (NPDB) adverse licensure actions taken against health care practitioners and licensed health care entities, and any negative actions or findings that a licensing authority, peer review organization or private accreditation entity has made against a health care practitioner or health care entity. They also expand the scope of entities that can query the NPDB. The rules do not change reporting requirements for hospitals, other health care entities, professional societies or medical malpractice payers.

The NPDB currently contains reports of adverse licensure, clinical privilege and professional society membership actions against physicians and dentists, Drug Enforcement Administration (DEA) adverse actions, United States Department of Health and Human Services Office of Inspector General (HHS OIG) Medicare and Medicaid exclusions, and medical malpractice payments made for the benefit of any health care practitioner. Hospitals, other health care entities that conduct peer review and provide health care services, and state medical and dental boards can query the NPDB. Individual practitioners can self-query. Entities required to report to the NPDB include medical malpractice payers; state medical and dental boards; the DEA; the HHS OIG; professional societies with formal peer review; and hospitals and other health care entities, such as health maintenance organizations.

The new rules expand states’ reporting obligations. States will be required to report certain adverse licensure actions taken against health care practitioners and health care entities by any authority of the state responsible for the licensing of such practitioners and entities. Licensing authorities currently need only report adverse actions related to professional competence or professional conduct. Under the new rules, they will be required to report any revocation, reprimand, censure, suspension, probation, dismissal or closure of a proceeding by reason of the practitioner or entity surrendering the license or leaving the state, and other loss of the license. States will also be required to report any negative action or finding that a licensing authority, peer review organization or private accreditation entity has finalized against a health care practitioner or entity. The new rule will also broaden access to the NPDB. In addition to the persons and entities that now have access, other state licensing authorities, agencies administering federal and state health care programs, state Medicaid Fraud Control Units, certain law enforcement agencies, and quality improvement organizations will be able to query the NPDB. These additional entities will have access only to information reported by states under the new rule; they will not have access to the information that entities have historically reported to the NPDB prior to the promulgation of the new rules.

For further information, please contact your regular Hinshaw attorney.

This alert has been prepared by Hinshaw & Culbertson LLP to provide information on recent legal developments of interest to our readers. It is not intended to provide legal advice for a specific situation or to create an attorney-client relationship.