Credentialing & Privileging | 03.06.20
NPDB Explains Length of Action Requirements for Reporting
by Donald Illich
Healthcare organizations and credentialing experts may have questions about length of action requirements for reporting clinical privileging actions to the NPDB. These frequently asked questions can have a pivotal impact on reporting: When does a restriction take effect, and does it matter how a restriction is written? How is proctoring affected by these length-of-action requirements? This article answers those questions, as well as provides a short introduction on reporting clinical privileges actions.
Reporting Clinical Privileges Actions
Hospitals and other healthcare entities must report “adverse clinical privileges actions” to the NPDB that meet the following NPDB reporting criteria: Any professional review action that adversely affects the clinical privileges of a physician or dentist for a period of more than 30 days. Other reporting criteria include the acceptance of the surrender of clinical privileges, or any restriction of such privileges by a physician or dentist (1) while the physician or dentist is under investigation by a healthcare entity relating to possible incompetence or improper professional conduct, or (2) in return for not conducting such an investigation or proceeding. Clinical privileges include privileges and medical staff membership (such as network participation and panel membership) in which a physician, dentist, or other healthcare practitioner is permitted to furnish medical care by a healthcare entity.
Clinical privileges are defined in NPDB regulations as “the authorization by a healthcare entity to a healthcare practitioner for the provision of healthcare services, including privileges and membership on the medical staff.” The term “medical staff” also includes network participation and panel membership. Practitioners with panel membership have a contract, agreement, or arrangement with a health maintenance organization or other carrier, either directly or through an intermediary. They have agreed to provide items or services to enrollees of the health maintenance organization. Participating in a network means the practitioner has negotiated a contracted rate with a health insurance company.
Adverse clinical privileges actions that must be reported to the NPDB are professional review actions based on a physician's or dentist's professional competence or professional conduct that adversely affects, or could adversely affect, the health or welfare of a patient. Generally, the entity that takes the clinical privileges action determines how the physician's or dentist's professional competence or professional conduct adversely affects the health or welfare of a patient.
Hospitals and other healthcare entities are encouraged to report clinical privileges actions taken against healthcare practitioners other than physicians and dentists when those clinical privileges actions are based on the practitioner's professional competence or professional conduct that does, or could potentially, negatively impact
Length of Action Requirement for Reporting Clinical Privileges Actions
For clinical privileges actions, the NPDB has consistently interpreted adversely affects to mean the impact of the restriction, and not the manner in which the restriction is written. If a physician's or dentist's privileges are adversely affected for longer than 30 days, the restriction must be reported to the NPDB, regardless of how the healthcare entity writes the restriction. For example, as described in the NPDB Guidebook, summary suspensions must be reported if imposed or in effect for longer than 30 days. However, reports submitted for summary suspensions, regardless of how the restriction was written, must be voided if the reported suspension did not ultimately last longer than 30 days. As is the case with any restriction, the reportable nature of the action is determined by the number of days privileges are restricted.
A healthcare entity may choose to structure a restriction based on when a healthcare practitioner demonstrates clinical competence, rather than attaching a specific timeframe to the action. A significant percentage of clinical privileging actions are reported to the NPDB as "indefinite" in length, placing the responsibility on the practitioner to demonstrate to the entity that they no longer need the restriction. If such an adverse action is in effect for more than 30 days, it is required to be reported.
A restriction begins at the time a physician or dentist cannot practice the full scope of their privileges and is reportable to the NPDB once that restriction has been in place for 31 days. For example, if a physician or dentist cannot perform certain procedures without proctor approval or presence, this is considered a restriction on privileges. The inability to practice the full scope of privileges without a proctor's presence or approval is a restriction. Once the physician or dentist is prohibited from performing the procedure without a proctor, their privileges are adversely affected. The number of cases required to be proctored at the time of imposition, or the expectation that a restriction be concluded in fewer than 31 days, is irrelevant for reporting purposes. The reportable nature of the action hinges on whether the restriction is in fact in effect for a period longer than 30 days.
For More Information
Visit the NPDB website. For technical questions related to billing, registration, and submitting a report, contact the Customer Service Center at help@npdb.hrsa.gov or 1-800-767-6732. The hours of operation for the NPDB Customer Service Center are Monday–Thursday 8:30 a.m.–6:00 p.m. and Friday 8:30 a.m.–5:30 p.m. EST. It is closed on weekends and federal holidays. Policy questions can be sent via email to NPDBPolicy@hrsa.gov. This article also contains information found in NPDB website’s Policy Corner.
Donald Illich is a writer-editor for the Division of Practitioner Data Banks, which is part of the Health Resources and Services Administration, Bureau of Health Workforce. He has written several articles for both internal and external audiences concerning the policies and operations of the NPDB, and he is a member of the Division’s Policy and Disputes Branch. He lives and works in Rockville, Maryland.