The Data Bank Merger and Its Impact on Health Care Providers

By: Jesse Adam Markos, Esq.
Wachler & Associates, P.C.

On May 6, 2013, the Secretary of the Department of Health and Human Services (HHS) issued a Final Rule announcing that the National Practitioner Data Bank (NPDB) and the Healthcare Integrity and Protection Data Bank (HIPDB) merged into one Data Bank: the NPDB. The merger resulted under Section 6403 of the Patient Protection and Affordable Care Act of 2010 (PPACA), which was designed to simplify Data Bank operations and eliminate duplicative data reporting and access requirements between the HIPDB and the NPDB. PPACA required the Secretary of HHS to establish a transition period to transfer all data in the HIPDB to the NPDB, and, once completed, to cease operations of the HIPDB. This merger represents an expansion of the information disseminated through the NPDB to certain users as query results will now include reports that were not previously available.

The NPDB was established by the Health Care Quality Improvement Act of 1986 (HCQIA) as an alert system designed to collect and disseminate information and protect the public from unfit health care practitioners. The HCQIA authorized the NPDB to collect reports of adverse licensure actions, adverse clinical privileges actions and adverse professional society membership actions against physicians and dentists; Drug Enforcement Administration (DEA) certification actions; Medicare/Medicaid exclusions; and medical malpractice payments made for the benefit of any health care practitioner. Information under the HCQIA was reported by medical malpractice payers, state medical and dental boards, professional societies with formal peer review, and hospitals and other health care entities (such as health maintenance organizations). Organizations that had access to this data system included hospitals, other health care entities that had formal peer review processes and provided health care services, state medical or dental boards and other health care practitioner state boards.

Section 1921 of the Social Security Act (section 1921), significantly expanded the scope of the NPDB. Final regulations implementing section 1921 were issued on January 28, 2010 and the NPDB began collecting and disclosing section 1921 information on March 1, 2010. Section 1921 required each state to adopt a system for reporting to the Secretary certain adverse licensure actions taken against all health care practitioners and entities (not just physicians and dentists) by any authority of the state responsible for the licensing of such practitioners or entities. It also requires each state to report any negative action or finding that a state licensing authority, a peer review organization, or a private accreditation entity had taken against a health care practitioner or health care entity. Information under section 1921 is reported by state licensing and certification authorities, peer review organizations, and private accreditation entities. Groups with access to this information included all organizations eligible to query the NPDB under the HCQIA, other state licensing authorities, agencies administering government health care programs (including private entities administering such programs under contract), state agencies administering or supervising the administration of government health care programs, state Medicaid fraud control units, certain law enforcement agencies, and utilization and quality control Quality Improvement Organizations (QIOs).

Section 1128E of the Social Security Act as added by Section 221(A) of the Health Insurance Portability and Accountability Act of 1996 created the HIPDB to combat fraud and abuse in health insurance and health care delivery. Section 1128E required Federal and state government agencies and health plans to report to the HIPDB the following final adverse actions: licensing and certification actions; criminal convictions and civil judgments related to the delivery of health care services; exclusions from government health care programs; and other adjudicated actions or decisions. However, a report to the HIPDB had limited professional and economic ramifications compared to the NPDB because Federal and state government agencies and health plans only had access to this information.

Although each data bank had unique characteristics, the requirements of both the HCQIA and Section 1921 overlapped with the requirements under Section 1128E. Prior to the merger, entities that had access to the NPDB and the HIPDB had to query each Data Bank separately to get all of the reports to which the entity was entitled. After the merger, reports that were stored in both the NPDB and HIPDB now reside solely in the NPDB. Reporting requirements remain essentially the same, with some minor technical changes to ensure consistency in reporting. For example, all reports must now be submitted within 30 days of the date the action was taken.

All health care providers should become familiar the specifics of the Data Bank merger, as a report to the NPDB may have significant professional and economic ramifications, including denial of credentialing, loss or limitation of hospital privileges, loss or limitation of licensure, exclusion from participation in health plans, increases in premiums, or exclusion from professional liability insurance. For additional information or assistance, contact a Wachler & Associates attorney at (248) 544-0888.