Credentialing & Privileging | 06.07.22
Reporting Clinical Privileges Actions to the National Practitioner Data Bank: Basic Requirements and Scenarios
by Donald Illich, NPDB
Hospitals must report certain adverse clinical privileges actions to the National Practitioner Data Bank (NPDB). This article describes these actions, and explains when reporting might be required if there is an investigation. It also tests your knowledge with real-life scenarios explaining what should be reported.
National Practitioner Data Bank
The NPDB’s mission is to improve health care quality, protect the public, and reduce health care fraud and abuse in the United States. The NPDB is a health workforce tool established by Congress in 1986 to assist organizations in making informed credentialing, privileging, and licensing decisions. It contains information on medical malpractice payments and certain adverse actions related to health care practitioners, entities, providers, and suppliers.
Basic Reportable Clinical Privileges Actions
For the NPDB to be effective, every professional review action that adversely affects a physician’s clinical privileges for more than 30 days must be reported. Examples include reducing, restricting, suspending, revoking, or denying privileges. Decisions not to renew privileges, if based on professional competence or conduct, must also be reported.
Actions are reportable when they are made final by a hospital. Summary suspensions exceeding 30 days are reportable even if not final. Additionally, those that are not yet in effect for more than 30 days, but are expected to last longer than 30 days, may be reported. If the summary suspension ultimately does not last more than 30 days, or is overturned or not upheld, the report must be voided.
All hospitals must report these actions within 30 calendar days of the date the action was taken. However, if a hospital discovers documentation of adverse actions that it had not reported, the hospital must promptly submit the related report(s). All required reports must be filed regardless of whether they are late.
Reporting and Investigations
Generally, a failure to renew privileges does not trigger a reportable event. However, a surrender/resignation of clinical privileges or a failure to renew clinical privileges while under investigation or to avoid investigation must be reported.
The term “investigation” is defined very broadly (investigations themselves are not reportable):
- Runs from start of inquiry until a final decision is reached or a decision to not pursue the matter is reached.
- Not limited to gathering of facts or how it is defined in hospital’s bylaws.
- Must concern the professional competence and/or professional conduct of the practitioner in question.
- Generally should be the precursor to a professional review action.
Clinical Privileges Scenario
Answer the questions about the reportability of clinical privileges actions in the following reporting scenarios. The answers to these questions can be accessed at the end of this article.
Part 1 Scenario and Questions:
Dr. X is an obstetrician/gynecologist at Memorial Hospital. He became the subject of a medical staff peer review after complications arose during several of his laparoscopic surgeries. Memorial Hospital sent a sampling of his cases for external peer review to determine whether there was a breach of the standard of care in his cases. The external peer review outcomes indicated that 75% of his cases did not meet the standard of care. The Medical Executive Committee decided to implement a review of Dr. X’s laparoscopic practice to include proctoring his next 15 cases. While the proctor can make recommendations, the proctor had no authority to take over the cases or veto Dr. X’s decisions in those cases.
Question 1: For NPDB reporting purposes, had Memorial Hospital begun an investigation into Dr. X’s situation?
A. No. There is no specific reference to an “investigation” in Dr. X’s situation thus far.
B. Yes. An investigation began when Dr. X became the subject of an external peer review following complications from his laparoscopic surgeries.
C. Yes. An investigation began when the Medical Executive Committee implemented a review of Dr. X’s laparoscopic practice to include proctoring his next 15 cases.
Question 2: If yes, should Memorial Hospital submit an NPDB report indicating Dr. X was under investigation for laparoscopic surgical complications?
A. Yes. Investigations for professional competence or professional conduct are reportable to the NPDB.
B. No. Investigations should not be reported unless a physician or dentist surrenders or fails to renew clinical privileges, or if privileges are restricted while the practitioner is under investigation by a health care entity for possible incompetence or improper professional conduct, or in return for not conducting an investigation. In such cases, the surrender or restriction must be reported.
Part 2 Scenario and Questions:
Several months later, Memorial Hospital received a complaint from a staff member about Dr. X. The staff member was uncomfortable with Dr. X’s request that she change the documentation of certain details of a difficult delivery in the patient’s medical records. Memorial Hospital began an investigation by interviewing staff and meeting with Dr. X about this specific incident of changing certain details in a patient’s medical records. Shortly thereafter, Dr. X submitted his resignation from the medical staff at Memorial Hospital. At the time of his resignation, Dr. X had not yet completed his proctoring requirement.
Question 1: How many reports should Memorial Hospital have submitted to the NPDB to fulfill their reporting obligations in this scenario?
A. One report. Memorial Hospital was required to submit a report when Dr. X resigned from the medical staff during an investigation into complaints he asked a staff member to change certain details in a patient’s medical records.
B. Two reports. Memorial Hospital was required to submit an Initial report detailing Dr. X’s proctoring requirement while performing laparoscopic surgeries. Later, Memorial Hospital was required to submit a Revision-to-Action report detailing Dr. X’s resignation following the investigation of the medical records tampering incident.
Question 2: What if there had been no “medical record tampering incident.” Instead, several months later, Dr. X resigned from the medical staff to take a more lucrative job elsewhere. At the time he resigned, he had completed only 10 of his 15 cases. Did Memorial Hospital have an NPDB reporting obligation concerning Dr. X?
A. No. If there was no medical records tampering incident, then there was no investigation concerning Dr. X.
B. Yes. The Medical Executive Committee’s focused review of Dr. X’s laparoscopic practice to include proctoring was an investigation that had not concluded. Therefore, Dr. X is considered to have resigned while under investigation.
For More Information
For additional information, visit the NPDB Web site at www.npdb.hrsa.gov. 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.
For answers to the above questions, click here.