NPDB Insights - August 2020

Is It Reportable?

A state Medicaid agency terminated the contract for participation of one of its Medicaid Managed Care Organizations (MCOs) after holding formal hearings and determining that the MCO had not maintained a sufficient network of providers to meet the state's access and quality requirements. Should the state agency report this action to the NPDB?

Yes. Any adverse action taken against a health care practitioner, entity, provider, or supplier by a licensing or certification authority of the state as a result of a formal proceeding, including revocations or suspensions of a certification agreement or contract for participation in a government health care program, must be reported to the NPDB. This termination of the MCO's contract for participation in the state's Medicaid program should be reported to the NPDB as a "Government Administrative" action.

Why Do I Have to Report to the NPDB?

Organizations such as state and federal agencies, hospitals, health plans, and medical malpractice payers are required by federal law to report to the NPDB when they make medical malpractice payments or take certain health care-related adverse actions concerning licensure, certification, or clinical privileges.

High-quality, consistently submitted reports are crucial to the NPDB fulfilling its role in promoting quality health care and protecting the public from health care fraud and abuse. Reports stored in the NPDB are records of medical malpractice payments and actions taken by authorized organizations regarding health care practitioners, entities, providers, and suppliers.

When they are making hiring, privileging, licensing, or certification decisions, eligible entities query the NPDB to obtain any reports that exist regarding their subject(s). Entities also query the NPDB during their mandatory 2-year review of clinical privileges or medical staff membership, or when investigating medical fraud or abuse.

The quality of information you receive from the NPDB depends on the quality and presence of the reports submitted to the NPDB. Reports provide entities with information on which to base their hiring, privileging, licensing, or certification decisions. Without timely and accurate reports, entities may not have as thorough an understanding of the practitioners or entities they are beginning a professional relationship with. This lack of information about the practitioner's professional history can lead to problems with patient safety, including medical liability risk.

By reporting to the NPDB, you and your organization are enhancing public safety across the country and within your own community by helping to prevent practitioners from moving state to state without disclosure or discovery of previous damaging performance.

For information on the federal laws and regulations that govern NPDB reporting, visit our Legislation & Regulations page. To learn more about reporting, including possible sanctions levied against those who do not report, visit our About Reporting page or Chapter E of the NPDB Guidebook.

Quick Tips: How to Write Report Narrative Descriptions

A narrative description is an important part of submitting reports to the NPDB. Every report submitted to the NPDB must include a narrative description with sufficient detail. This ensures that future queriers have a clear understanding of what the subject of the report is alleged to have done and the nature of or reasons for the event upon which the report is based.

Narrative descriptions should:

• State the facts of the case
• Summarize the official findings of the action taken
• Include a description of the circumstances that led to the action taken
• Be no longer than 4,000 characters

Narrative descriptions should not include:

• URLs or references to external websites, as these may include personally identifiable information, language, or information that is not within the NPDB reporting guidelines.
• The proper names of or identifying information about any individual except for the subject of the report. Other individuals may be characterized in general terms such as "the patient," "the chief of staff," etc.

For more information on the requirements and restrictions for report narrative descriptions, see Chapter E of the NPDB Guidebook. Entities may wish to consult with their legal counsel regarding the wording of the narrative before submitting reports to the NPDB.

Dear NPDB

What is the difference between One-Time and Continuous Query?

A query is one of the many ways in which eligible entities interact with the NPDB. A query is a search for information stored within the NPDB regarding a physician, dentist, or other health care practitioner or organization. An entity's ability to query and its requirements for querying are determined by federal law. To help entities fulfill their querying requirements, the NPDB offers two querying options.

One-Time Query

Continuous Query

A One-Time Query provides a single query response for a physician, dentist, or other health care practitioner or organization. Upon submitting a One-Time Query request, you will receive a snapshot of all reports in the NPDB concerning the specified practitioner or organization at the time of your request, but you will not be notified of any new reports after your query has been processed (other than corrections or voids within 3 years). If, after you submit your One-Time Query, you wish to know of any subsequent reports submitted on the practitioner or organization, you must submit another One-Time Query.

Continuous Query allows you to enroll a physician, dentist, or other health care practitioner in a year-long subscription service so that you receive an initial One-Time Query response and rolling notifications for all new actions related to the enrolled practitioner. While the practitioner is enrolled in Continuous Query, you will receive email notifications and disclosures of reports within 24 hours of the NPDB's receipt of all new or updated reports on the practitioner. Once you activate Continuous Query, you will not need to submit any additional One-Time Query requests for any of your practitioners for the duration of their year-long Continuous Query enrollments.

For the same price as a single One-Time Query, Continuous Query monitors your enrolled practitioners 24 hours a day, 365 days a year, and keeps you informed about any new or updated reports. Like a One-Time Query, Continuous Query meets all legal and accreditation requirements for querying the NPDB.

To get started with Continuous Query, your account administrator must complete the following steps:

1. Sign In to your NPDB account
2. Go to the Administrator Options page
3. Select Activate Continuous Query and then submit the form

For more information about enrolling in Continuous Query, visit the How to Use Continuous Query links on our Continuous Query page.