NPDB Insights - September 2019

Is It Reportable?

A health plan terminated contracts with several psychologists in its network because the plan determined it already had too many psychologists in that geographic area. Should this action be reported?

No. While health plans are required to report actions that meet the definition of an "other adjudicated action or decision," that definition specifically excludes business or administrative decisions by health plans that result in contract terminations unrelated to health care fraud or abuse, or quality of care issues. The contract terminations taken by this health plan were based on business decisions regarding its network and were not related to health care fraud or abuse, or the quality of health care delivered by the practitioners involved.

What Can I Share with My Surveyor?

If your organization is going through an accreditation survey, you may have concerns about what you can share with the surveyor.

Due to confidentiality provisions, your organization is not allowed to share query responses with the surveyor or anyone outside of the hiring, credentialing, or licensing process. However, you may share your historical query activity and enrollment confirmations for specific practitioners to prove your organization is querying as required.

To obtain a list of one-time queries, follow the steps below:

1. Sign in
2. On the Select an Option page, select Query
3. On the Query Options page, select View Historical Queries
4. Search for a specific time period, for a certain practitioner's name, or perform an Advanced Search
5. Select Download on the Historical Query Summary page

To obtain a list of continuous query enrollments, follow the steps below:

1. Sign in
2. On the Select an Option page, select Query
3. On the Query Options page, select Manage Enrollments
4. Select Download and then Practitioner Summary from the drop-down menu

For additional information about confidentiality provisions, visit Guidebook, Chapter D.

Is Your Health Plan Reporting?

Different types of organizations have distinct reporting requirements based on their statutory authorities. Health plans generally fall under two statutory authorities. Depending on the types of actions you take, you may have to report multiple actions, including the following:

• Adverse clinical privileges actions
• Other adjudicated actions (contract terminations)
• Medical malpractice payments
• Civil judgments

Reporting clinical privileges actions and reporting other adjudicated actions sometimes causes confusion for health plans because of the need for multiple reports.

A panel membership or network participation action is a type of adverse clinical privileges action, also known as a professional review action. Any professional review action that adversely affects the panel membership or network participation of a physician or dentist for more than 30 days is reportable.

A clinical privileges action must also be reported when your health plan accepts the surrender of clinical privileges (or any restriction of such privileges) by a physician or dentist either while under or to avoid an investigation that is related to possible incompetence or improper professional conduct.

An other adjudicated action, such as a contract termination, is an action your health plan takes against a health care practitioner, provider, or supplier, that includes the availability of due process and is related to the delivery of health care items or services.

Automatic actions—actions with no due process—are not reportable. However, if an action follows due process, it is reportable.

For additional reporting guidance, view our Reporting infographics.