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by Richard D. Weber, J.D.
MDA Legal Counsel
Published in the February 2000 issue of the Journal

Question: I read that a new data bank has been started by the federal government that is different from the National Practitioner Data Bank which has been around for a number of years. Is this true? If so, please explain it and how it differs from the existing National Practitioner Data Bank. Will the public be given access to this information?

Answer: The new Healthcare Integrity and Protection Data Bank (HIPDB), not to be confused with the National Practitioner Data Bank (NPDB), was mandated by the Health Insurance Portability and Accountability Act of 1996. The Department of Health and Human Services issued its final rule on Oct. 26, 1999, so your question is certainly very timely.

The HIPDB went into limited service to receive information in November 1999. It is expected to begin accepting requests for information in early 2000.

The specific intent of Congress was to combat health care fraud and abuse. The law applies to all health care providers, suppliers, and practitioners, which obviously includes dentists. Reporting is required with respect to:

  • Civil judgments, except malpractice judgments, in federal and state courts related to the delivery of health care.
  • Federal or state criminal convictions related to the delivery of health care.
  • Actions by federal and state agencies responsible for the licensing and certification of health care providers.
  • The exclusion of health care providers from participation in federal or state health care programs.
  • "Any other adjudicated actions or decisions that the HHS Secretary establishes by regulation."

Federal and state law-enforcement organizations, licensing boards and private health plans are required to report within 30 days of a final action or face a penalty of up to $25,000 for each action not reported. The entities required to report must provide information on all reportable adverse actions taken since Aug. 21, 1996, the date of enactment of the legislation.

Access to the information is limited to governmental agencies and private health plans required to report. Subjects may obtain access to their own reports. The public may not access the information. Significantly, hospitals are not allowed access to this new data bank.

Although Congress intended to combat health care fraud and abuse, it appears that the final rule is more expansive. It includes adverse actions that the reporting entity may unilaterally conclude should be reported, even though there is no specific finding of health care fraud and abuse. The final rules exclude administrative fines or citations, corrective action plans and other personnel actions unless they are connected to the billing, provision, or delivery of health care services, and taken in conjunction with other licensure or certification actions such as revocation, suspension, censure, reprimand, probation, or surrender.

While there may be some overlap in the information collected by the two data banks, and both are run by the Health Resources and Services Administration, significant differences do exist. The chart included with this article summarizes the differences between the NPDB and HIPDB.

 NPDB    
HIPD   
 People Covered 
       People Covered  
Physicians and dentists          All health care providers, suppliers and practitioners  

Data Reported

Information on malpractice payments; adverse licensure, clinical privileges and professional society membership actions Information on final actions including civil judgments and criminal convictions relating to health care; adverse licensing and credentialling actions; and federal or state health care program exclusions.

Access

Hospitals, health care entities with a formal peer-review process, professional societies, state licensing boards and practitioners seeking information about themselves and certain attorneys Federal and state government agencies, health plans and providers seeking information about themselves.

Required Queries

Hospitals must query the data bank relative to the professional staff No required query.

Both federal statutes preclude public access to the respective data banks. However, there has been strong support, including proposed legislation, to open the NPDB to public scrutiny. The American Medical Association and American Dental Association are strongly opposed to making the data bank information public. Information regarding malpractice settlements in the NPDB make public scrutiny even more objectionable. The public would not understand that malpractice settlements often have no bearing on the quality of practice or ability of the physician or dentist.


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