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Why the National Practitioner Data Bank Matters to You and Your Clients. Mark V. Gende, Esq. Sweeny, Wingate & Barrow, PA Columbia, South Carolina. What is the NPDB?. Information clearing house Collect and release certain information Professional competence and conduct Physicians Dentists

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Why the national practitioner data bank matters to you and your clients

Why the National Practitioner Data Bank Matters to You and Your Clients

Mark V. Gende, Esq.

Sweeny, Wingate & Barrow, PA

Columbia, South Carolina


What is the npdb
What is the NPDB? Your Clients

  • Information clearing house

  • Collect and release certain information

  • Professional competence and conduct

  • Physicians

  • Dentists

  • Other health care practitioners


Why did congress create npdb
Why did Congress Create NPDB? Your Clients

  • Increasing medical malpractice litigation

  • Need to improve quality of medical care

  • National problem states unable to address

  • Restrict incompetent physicians movement

  • Promote effective peer review by

    • Incentives (fines)

    • Protection (confidentiality)

  • Reduce health care fraud and abuse (NIPDB)


A brief history of the npdb
A Brief History of the NPDB Your Clients

  • Health Care Quality Improvement Act of 1986 (Title IV)

  • Medicare and Medicaid Patient and Protection Act of 1987 (Section 1921; NPDB)

  • Health Insurance Portability and Accountability Act of 1996 (Section 1128E; HIPDB)

  • Patient Protection and Affordable Care Act of 2010 (merge NPDB and HIPDB)


The merger of npdb and nipdb
The Merger of NPDB and NIPDB Your Clients

  • NIPDB consolidated with NPDB May 6, 2013

  • Final regulations published April 5, 2013, Codified at 45 CFR Part 60

  • Draft NPDB Guidebook published November 2013

  • Comment period on Revised NPDB Guidebook closes on February 5, 2014

  • New NPDB Guidebook will be posted at http://www.npdg.hrsa.gov


What about the npdb is important to litigators
What about the NPDB is Your Clientsimportant to litigators?

  • Basic reporting requirements

  • Basic querying access

  • Where you are likely to encounter the NPDB

  • The NPDB web site


Basic reporting
Basic Reporting Your Clients

  • Who is reported?

    • Physicians

    • Dentists

    • Other practitioners

    • Entities

    • Providers

    • Suppliers


Basic reporting1
Basic Reporting Your Clients

  • Who reports?

    • Medical malpractice payers

    • Hospitals

    • Other self-insured healthcare entities

    • Professional societies

    • Health plans

    • Peer review organizations

    • Various State and Federal agencies


Basic reporting2
Basic Reporting Your Clients

  • What is reported?

    • Medical malpractice payment from

      • A written claim

      • A judgment

    • Certain adverse clinical privileges actions

    • Certain adverse professional society membership actions

    • DEA controlled substances registration actions

    • Exclusions from Medicare, Medicaid


Basic reporting3
Basic Reporting Your Clients

  • When is a report made?

    • Within 30 days from

      • Date action taken

      • Date payment made

  • What are the basic report formats?

    • Medical Malpractice Payment Report (MMPR)

    • Judgment or Conviction Report

    • Adverse Action Report


Basic reporting4
Basic Reporting Your Clients

  • What is in a report?

    • Age of claimant

    • Sex of claimant

    • Patient type (in or out)

    • Initial Event (medical condition of patient)

    • Procedure performed

    • Claimant’s allegation

    • Associated legal and other issues

    • Outcome


Basic reporting5
Basic Reporting Your Clients

  • Example of a MMPR

    A 65-year-old male outpatient had a prostate exam by Dr. A. Six months later, the patient was diagnosed by Dr. B with prostate cancer and underwent surgery. One year later, the patient sued Dr. A for alleged failure to diagnose. A settlement was reached in the amount of $250,000.

    (Source: NPDG Guidebook, September 2001)


Basic querying
Basic Querying Your Clients

  • What is querying?

    • Ability to access NPDB reports

  • Who must/may/may not query?

    • Hospitals (must)

    • State licensing boards

    • Professional societies

    • Other health care entities

    • Attorneys

    • Physicians, dentists, practitioners concerning self

    • Medical malpractice payers (cannot)


Attorney querying
Attorney Querying Your Clients

  • Plaintiffs’ attorneys

    • Filed medical malpractice action/claim

    • Against hospital

    • Evidence reveals hospital failed to query

    • Practitioner also named in the action/claim

  • Defense attorneys

    • Not permitted to query

    • Defendant practitioner can self-query


Npdb and the litigator
NPDB and the Litigator Your Clients

  • Advise your client early about NPDB reporting

    • As it relates to settlement

    • As it relates to reporting

    • Memorialize your advice

  • Clients surprised by NPDB reporting

    • File grievances

    • May impact representation opportunities

      • With other medical providers

      • With your carrier


Npdb and the litigator1
NPDB and the Litigator Your Clients

  • Carrier asks you to draft the report

    • Consult the Guidebook

    • Coordinate draft with carrier

    • Coordinate draft with client

    • Memorialize all communications


Npdb and the litigator2
NPDB and the Litigator Your Clients

  • Challenging a filed report

    • Retained by a practitioner

    • Well defined appeals process

    • Typically courts have upheld the NPDB


Leaning more about the npdb
Leaning More about the NPDB Your Clients

  • The Draft NPDB Guidebook

  • The U.S. Department of Health and Human Services web site

    • http://www.npdb.hrsa.gov

    • Wealth of interesting statistical information

    • Statistical Data / NPDB research statistics


United states
United States Your Clients