Transcript NPDB-HIPDB Updates Illinois Association Medical Staff

HIPDB: Reporting Responsibilities
Federation of Chiropractic Licensing Boards
81st Annual Congress
May 4, 2007
LCDR Shari W. Campbell, DPM, MSHS
U. S. Department of Health and Human Services
Health Resources and Services Administration
Bureau of Health Professions
Practitioner Data Banks Branch
Overview
 HIPDB Background
 Report Data
 Compliance Activities
 System Improvements
 New Initiatives
HIPDB
Background
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.
HIPDB Background
 Established through Section 1128E of the
Social Security Act as amended by
Section 221(a) of Public Law 104-191, the
Health Insurance Portability and
Accountability Act of 1996 (HIPAA)
 Final regulations governing the HIPDB are
codified at 45 CFR Part 61
 All final adverse actions taken on or after
August 21, 1996 must be reported
By Law, Who Must Report?
 State Government Entities
 Federal Government Entities
 Health Plans
Who May Query the HIPDB?
 Federal and State Government Agencies
 Health Plans
 Health Care Providers, Practitioners and
Suppliers (self-query only)
 Researchers (non-identifiable statistical
information)
Who is Reported?
 Health Care Providers
Examples: Hospitals, Health Plans, PPOs, Medical Group
Practices
 Health Care Practitioners
Examples: Chiropractors, Podiatrists, Athletic Trainers,
Registered Nurses, Certified Nurse Assistants
 Health Care Suppliers
Examples: Durable Medical Equipment Suppliers,
Pharmaceutical Suppliers and Manufacturers, Billing
and Transportation Service Suppliers
What is Reportable?
 Federal and State licensing and
certification agencies must report
final adverse actions* that are taken
against health care:
 Providers
 Practitioners
 Suppliers
*Regardless of whether the final adverse action is the subject of a pending appeal
What is Reportable?
 Licensing and certification actions:
 Revocation, Suspension, Probation, Censure,
Reprimand
 Any other loss of license or certification, or right to
apply for, or renew a license whether by voluntary
surrender, or non-renewal
 Any other negative action or finding that is publicly
available information
What is Reportable?
 Criminal Convictions
 Federal and State Prosecutors must report criminal
convictions* related to the delivery of a health care item or
services
 Civil Judgments
 Federal and State attorneys and health plans must report civil
judgments* related to the delivery of a health care item or
services
 Exclusions
 Federal and State Government agencies must report health
care providers, suppliers, or practitioners excluded* from
participation in Federal or State health care programs
*Regardless of whether the conviction is the subject of a pending appeal
What is Reportable?
 Other Adjudicated Actions
 Federal and State government agencies and
Health Plans must report other adjudicated
actions, * which are defined as:
 Formal or official final actions taken against health
care practitioners, providers, or suppliers, which
include the availability of a due process mechanism;
and
 Are based on acts or omissions that affect or could
affect the payment, provision, or delivery of a health
care item or service
*Regardless of whether the exclusion is the subject of a pending appeal
What is not Reportable?
 Medical Malpractice Payments
 Settlements in which no findings or admissions
of liability have been made
 Temporary Actions; i.e. summary or emergency
HIPDB
Data
What is in the HIPDB?
Practitioner Reports
State Licensure 193,910
1%
4%
State & Fed Exclusions 45,827
0%
Judgments or Convictions 10,693
18%
Gov't Admin 2,283
Health Plan 3,626
DEA 468
76%
Cumulative Data as of 12/31/06
What is in the HIPDB?
Practitioner Reports
8%
2% 0%
0%
State Licensure 28,207
8%
State & Fed Exclusions 2,916
Judgment or Conviction 2,595
Health Plan 529
82%
Gov't Admin 120
DEA 23
Reports received in 2006
What is in the HIPDB?
Organizations
State Licensure 2,061
2%
State & Fed Exclusions 711
0%
26%
Judgments or Convictions 266
Gov't Admin 4,805
Health Plan 159
DEA 15
60%
9%
3%
Cumulative Data as of
12/31/06
What is in the HIPDB?
Organizations
1%
State Licensure 197
14%
7%
4%
73%
1%
State & Fed Exclusions 104
Judgment or Conviction 57
Health Plan 20
Gov't Admin 1,032
DEA 15
2006 Data
HIPDB QUERIERS
5%
8%
1.2%
Self-Queries 5.7%
15.6%
Gov't Hospitals 15.6%
Health Plans 64%
Government Health
Prog 1.2%
State Boards 8%
64%
Other Service
Providers 5%
2006 Data
Types of Reports on Chiropractors
2004
2005
2006
Licensure
Malpractice
184
235
309
213
1135
208
Exclusions
Health Plan
JOCR
Clinical
Privileges
134
111
15
6
48
128
10
5
69
96
18
13
Total # of
Reports
1628
656
251
335
43
24
Note: Data represents the date that the action was submitted to the NPDB or HIPDB
Types of Reports on Chiropractors
1200
1000
Licensure
Malpractice
Exclusions
Health Plan
JOCR
Clin Priv
800
Number of
Reports
600
400
200
0
2004
2005
2006
Note: Data represents the date that the action was submitted to the NPDB or HIPDB
Chiropractor Licensure Actions
100%
80%
60%
Action Taken 2006
Action Taken 2005
Action Taken 2004
Action Taken 2003
40%
20%
0%
Reported
2004
Reported
2005
Reported
2006
HIPDB
Compliance Activities
Compliance Activities
 Convey the importance of timely reporting



Holding Policy Forums and talking with leadership of composite State
licensing boards
Presenting to Associations/Federations of State licensing boards
Presenting to State Association Medical Staff Services
 Regulations



Mandates reporting within 30 days of the date of the final action.
NPDB: Title IV of Public Law 99-660, the Health Care Quality
Improvement Act of 1986, as amended and its implementing regulations
(45 CFR Part 60)
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)
Compliance Activities
 Monitor Timely Reporting



Compare actions documented on State Licensing Board web sites to
actions reported to the NPDB and/or HIPDB
Identify and contact States that have not reported any actions to the
NPDB and/or HIPDB
Search other publicly available information for actions and payments
that should have been reported
 Review reports that are filed and later voided
 Review a limited number of report narratives to determine
if they are legally sufficient:

Must include enough information so that future queriers knowing
nothing about the events giving rise to the report will have an
understanding of what the subject practitioner is alleged to have done,
the nature of the action taken and the reasons for the report
Compliance Activities
 Compare NPDB payment reports to the NAIC summary
payment reports (Supplement A to Schedule T)
 Review Medical Malpractice Payment Reports that mention
High-Low agreements in the narrative to determine if the
payment was made for the benefit of the:


Practitioner (reportable)
Insurer to avoid the risk of a higher payment when the finder of fact
ultimately determines that the practitioner had no liability (not reportable)
 These reporters are asked to void the report
 Monitor the eligibility of Data Bank Registrants
 Monitor for violation of Confidentiality Rules
HIPDB
System Improvements
June 18, 2007 System Release
 Ability to correct a Revision-to-Action Report (IQRS and ITP)
 Ability to update a Subject Address when entering a Dispute
Statement or Secretarial Review Request
 Increase all Report Narratives and Subject Statements to
4,000 Characters
 Enhanced ITP Client Program for Password Encryption


New version will be posted on the informational website and available for
download as of April 30, 2007
New version must be used on June 18 - previous version will not work
June 18, 2007 System Release

Display most recent Entity Information


Section A will be expanded to include the most recent reporter name
and address (if it has changed) since the submission date
Five variations

No change in reporter information

Updated reporter information

Original reporter is inactive with no successor

Original reporter is inactive with a successor

Original reporter is inactive with a successor, the successor is
inactive
No change
Reporter information
is current
Original Reporter inactive with no
Successor
Reporter is inactive
with no successor
Original Reporter inactive with a
Successor
Reporter is inactive
with a successor
Successor POC is
provided if present
Original Reporter inactive with a
Successor
Reporter is inactive
with a successor
Successor POC is
provided if present
Original Reporter inactive with a
Successor, and the Successor is also
inactive
Reporter is inactive
with a successor, and
the successor is also
inactive
Successor POC is
provided if present
June 18, 2007 System Release
 Limit Registration Renewal Grace Periods


There will be a limit of three months or four (4) grace renewals, whichever
is longer, in which the entity is permitted access to the system without
actually renewing
Once the limit is passed, the system will permit the user to renew only.
There will not be a grace period provided to use the system while the
renewal is mailed and processed
 Grace Period For Expired Entity Registrations
 The system considers an entity to be “inactive” once their registration
expires. Report change notifications are not sent to inactive entities
 To prevent an entity with an expired registration from missing report
change notifications, a 90 day grace period will be established
June 18, 2007 System Release
 Addition of another option to Automatic Reinstatement Data
Element (IQRS and ITP)
 Currently, an entity can select only "yes" or "no" in response to whether a
reinstatement is automatic at completion of the adverse action period
 Add a third response option:
 Yes
 Yes, with conditions (requires a Revision to Action Report when status
changes)
 No
Automatic Reinstatement Options
Now three response
options
Other Recent System Improvements
 Historical Summaries


Users can retrieve historical summaries of their queries and reports back to
June 2000. Use entity name and specific date range for the search
Limited to one-year increments within three years of the search date
 Query/Report Response Availability

Available via IQRS for 45 days, previously only available for 30 days
 Timely Reporting

Notice regarding timeliness of reporting included on the Report Verification
Document (RVD)
NPDB - HIPDB
New Initiatives
Proactive Disclosure Service (PDS)
Section 1921: expansion of the NPDB
Proactive Disclosure Service (PDS)
 The intent of PDS is to protect the public and
improve the quality of health care by providing
information to entities as soon as it is received by
the Data Banks

Average querier receives a new Data Bank report in 302
days
 Opens as a Prototype on May 1, 2007
 Prototype status expected to last 18 months for
evaluation purposes
The Current Query Process
 Hospitals, other health care entities, including
MCOs, State and Federal agencies query the Data
Bank by requesting information on a routine
schedule
 A seamless, secure internet system permits a
user to query one or both Data Banks
 Users query in preparation for reappointment or
during the re-credentialing process (typically
every 2 or 3 years)
 The query fee is $4.75 per name, per Data Bank
The PDS Process
 A subscription service that notifies





subscribers of new information on any of
their enrolled practitioners within one
business day of Data Banks receipt of the
information
Notification is sent via email; the entity must
log in to retrieve the information
Offered as an alternative to and not a
replacement of the current querying method
Report format, information and data reported
to the Data Banks will not change
Can use PDS for NPDB, HIPDB or both
Fee is $3.25 per enrolled subject / per year
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
PDS Enrollment

When a practitioner is first enrolled in the
PDS, the enrollment confirmation will include
all reports on the practitioner to ensure the
entity is aware of all existing reports in the
Data Banks
 This is included in the price of PDS

Enrollment confirmations for enrolled
practitioners and previously enrolled
practitioners whose enrollments have been
cancelled within the last four years will be
available, upon demand
Report Notification
Entity receives email
notification
Report Notification
Report Notification
Report Notification
Users always have
access to all the
active reports on a
subject
Report Notification
Other PDS Characteristics
 Data Bank report availability:

Report disclosures will be available on the
IQRS for 45 days in PDF format

All reports in the Data Banks for each enrolled
practitioner will be available upon demand
Other PDS Characteristics
 Subscribing to the service:


A 12-month subscription period for each
enrollee (practitioner)
The subscription expires on the last day of
the same month of the following year
 i.e., all practitioners enrolled in May 2007
regardless of the exact date of enrollment
will have a subscription expiration date of
May 31, 2008
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.
 Enacted to provide protection to program
beneficiaries from questionable health care
practitioners and to improve the anti-fraud provisions
of Medicare and Medicaid.
Section 1921
 Notice of Proposed Rule Making
 Published in the Federal Register on March 21,
2006
 Expected final in October 2007
 Expands the NPDB
 Major reports Added by Section 1921
 Adverse actions or findings by private accrediting
organizations such as:
NCQA
 URAC
 The Joint Commission
 The Commission on Accreditation of
Rehabilitation Facilities

Section 1921

Adverse licensure actions taken against all
health care practitioners


Broader than issues related to professional
competence and conduct
Adds the same type of licensure actions
currently reported to the HIPDB
Reportable: without Section 1921
NPDB
 Medical Malpractice Payments
 Adverse Actions (physicians and
dentists)
 Licensure
 Clinical Privileges*
 Professional Society
Membership*
 Medicare and Medicaid Exclusions (all
practitioners)
 DEA Actions (all practitioners)
*other practitioners may be reported
HIPDB*
 Licensure Actions
 Medicare and Medicaid Exclusions
and other exclusions from Federal
or State Health Care Programs
 Health Care Related Criminal
Convictions, or Civil Judgments
 Other Adjudicated Actions or
Contract Terminations
*Practitioners, Providers and Suppliers
Reportable: with Section 1921
NPDB
 Medical Malpractice Payments
 Adverse Actions (physicians and
dentists)
 Licensure
 Clinical Privileges*
 Professional Society
Membership*
 Medicare and Medicaid Exclusions (all
practitioners)
 DEA Actions (all practitioners)
*other practitioners may be reported
HIPDB*
 Licensure Actions
 Medicare and Medicaid Exclusions
and other exclusions from Federal
or State Health Care Programs
 Health Care Related Criminal
Convictions, or Civil Judgments
 Other Adjudicated Actions or
Contract Terminations
*Practitioners, Providers and Suppliers
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 for Section 1921 reports
Access without Section 1921
NPDB
HIPDB
 Hospitals and other Health Care
 Federal and State




Entities
State Medical and Dental
Licensing Authorities
Professional Societies with
formal peer review
Practitioners (self-query only)
Researchers (non-identifiable
statistical information)
Government Agencies
 Health Plans
 Practitioners, Providers and
Suppliers (self-query only)
 Researchers (non-identifiable
statistical information)
Access with Section 1921
 NPDB & Section 1921





Hospitals and other
Health Care Entities
State Medical and Dental
Licensing Authorities
Professional Societies
with formal peer review
Practitioners (self-query
only)
Researchers (nonidentifiable statistical
information)
 Section 1921 Only




State Medicaid Fraud
Control Units
Agencies administering
Federal and State Health
Care Programs
U.S. Comptroller General
U.S. Attorney General
and other law
enforcement officials
Reference Information
 Web Site - www.npdb-hipdb.hrsa.gov






NPDB and HIPDB Guidebooks
Interactive Training
Brochures and Fact Sheets
Statistics
Annual Reports
Instructions for Reporting and Querying
 Customer Service Center - 1-800-767-6732
(1-800-SOS-NPDB)
Contact Information
LCDR Shari W. Campbell, DPM, MSHS
Policy Analyst
Practitioner Data Banks Branch
(301) 594-4251
[email protected]