National Practitioner Data Bank

Healthcare Integrity and Protection Data Bank

1. What information is in the National Practitioner Data Bank (NPDB)?

   The NPDB collects the following information:

   1. Medical malpractice payments (all health care practitioners).
   2. Adverse actions: based on reasons relating to professional competency and conduct.
      1. Licensing actions (physicians/dentists only).
      2. Clinical privilege actions (required for physicians/dentists, voluntary reporting for other health care practitioners).
      3. Professional society membership actions (required for physicians/dentists, voluntary reporting for other health care practitioners).
   3. Drug Enforcement Administration actions (all health care practitioners).
   4. Medicare/Medicaid Exclusions (all health care practitioners).

   For more information on the above actions please review the NPDB Guidebook which can be found under the Publications category on the Data Banks home page.

2. How do I determine if my organization is eligible to query the National Practitioner Data Bank (NPDB)?

   The Health Care Quality Improvement Act of 1986 (HCQIA) which defines the types of organizations that are eligible to query the National Practitioner Data Bank (NPDB) specifies that State licensing boards, hospitals, and other healthcare organizations and professional societies that provide health care services and follow a formal peer review process to further quality care are eligible to query the NPDB. However, each healthcare organization is responsible for determining and certifying its eligibility to participate in the NPDB. The eligibility certification must be submitted in writing

   You should review the statutory definition to determine whether your organization meets these requirements. The HCQIA is located on the Data Banks home page under the Legislation & Regulations category. Or, see page B-1 of the Eligible Entities chapter of the NPDB Guidebook, which is available under the Publications category on the Data Banks home page. (Also in Registration FAQ and Eligibility Criteria FAQ.)

3. Why should my organization query the National Practitioner Data Bank (NPDB)?

   The NPDB contains information that is designed to augment other information collected and used in making a decision about whether to affiliate (i.e., licensure, contract, employment, or professional society membership) with a healthcare practitioner. The information includes medical malpractice payments, adverse licensure, clinical privilege, professional society actions as well as Drug Enforcement Administration actions against registrations, and Medicare/Medicaid Exclusions. Hospitals are required by law to query. Querying is voluntary for other healthcare organizations.

   Mandatory Querying: The law requires hospitals to query when a practitioner applies for permanent or temporary medical staff appointment or clinical privileges, and every two years thereafter, and when being considered for reappointment to the medical staff. In addition, hospitals are required to query the NPDB when a practitioner wishes to add to or expand existing clinical privileges. Enrollment of a practitioner in the Proactive Disclosure Service Prototype (PDS 24/7 notification) meets a hospital's mandatory querying requirement for that practitioner.

   Voluntary Querying: Hospitals may query at other times as necessary for professional review activities. Other healthcare organizations that provide health care services and have a formal peer review process, including professional societies, may query when entering an employment or affiliation relationship with a physician, dentist (voluntary for other health care practitioners), or in conjunction with professional review activities. State licensing boards may query at any time on physicians, dentists, and other health care practitioners. Health care practitioners may self-query at any time to obtain copies of reports which may have been submitted concerning them. Plaintiff's attorneys or a plaintiff representing him or herself (pro se) may query under certain limited circumstances.

4. Can a plaintiff’s attorney or the plaintiff representing him or herself (pro se) query the Data Bank?

   A plaintiff’s attorney or a plaintiff representing him or herself (pro se) is permitted to obtain information from the National Practitioner Data Bank (NPDB) under the following limited conditions:

   • A medical malpractice action or claim must have been filed by the plaintiff against a hospital in a State or Federal court or other adjudicative body.
   • The practitioner on whom the information is requested must be named in the action or claim.
   • The plaintiff’s attorney must provide independent proof that the hospital did not make the legally required query.

   Evidence that the hospital failed to request information from the NPDB may be obtained by the plaintiff from the hospital through the discovery process. This evidence is not available to the plaintiff through the NPDB; it must be obtained from independent sources. Plaintiff’s attorney requests for NPDB information and proof of (1) the existence of the litigation, (2) the naming of the practitioner in the litigation, and (3) the failure of the hospital to make the required query should be sent to the Policy and Analysis Branch, Division of Practitioner Data Banks, 5600 Fishers Lane, 8-103, Rockville, MD 20857.

   A plaintiff’s attorney or the plaintiff representing him or herself (pro se) that meets the above criteria and receives NPDB information can only use the information in a legal action or claim against the hospital, not against the practitioner. Plaintiff's attorneys are not permitted to query the Healthcare Integrity and Protection Data Bank (HIPDB).

5. Does the National Practitioner Data Bank (NPDB) accept reports on actions that occurred prior to September 1, 1990?

   No. As specified in the governing regulations codified at 45 CFR 60, only reports of actions taken on September 1, 1990, or later can be submitted to the NPDB.

6. If a State Licensing board updates its files on its licensed practitioners every twelve months, are they allowed to query the National Practitioner Data Bank (NPDB) every twelve months?

   Yes, State licensing boards may query the Data Banks at any time. However, the State may find it less expensive to enroll the licensees in the Proactive Disclosure Service Prototype (PDS 24/7 notification) for continuous querying rather than querying every twelve months. (Also in Querying FAQ.)

7. What is the deadline for submitting a Medical Malpractice Payment Report (MMPR)?

   Medical malpractice payers, including self-insured organizations, are required to report a payment within 30 days from the date the payment was made. Missing the deadline does not excuse the reporter from filing a required payment report. The penalty for not reporting a medical malpractice payment is up to $11,000 dollars per occurrence. The reporting organization must also send a copy of the final report to the State licensure board. (Also in Reporting FAQ.)

8. What is the deadline for reporting adverse licensure actions to the National Practitioner Data Bank (NPDB)?

   State licensure boards must submit reports within 30 days from the date the adverse licensure action was taken. Missing the deadline does not excuse the reporter from filing the required report. (Also in Reporting FAQ.)

9. What is the deadline for submitting clinical privileges action reports?

   Hospitals and other health care organizations are required to report adverse clinical privilege or panel membership actions that are in effect for more than 30 days. A clinical privilege or panel membership action for a definite or specific time period, lasting 30 days or more, should be submitted within 30 days of the date that the action was taken. A clinical privilege or panel membership action in place for an indefinite period becomes reportable on the 31st day the action is in effect. For example, an adverse action was taken on May 1st and it is in effect indefinitely; on June 1st the action is now in effect for more than 30 days. As a result, the action must be reported within 30 days of June 1st or, in other words, by July 1st. Missing the deadline does not excuse the reporter from filing a required report. The reporting organization must also send a copy of the final report to the State licensure board. (Also in Reporting FAQ.)

10. Why is the deceased date included on the subject database form?

    The deceased date is a required field for report submission, so it is included within the subject database for use by reporters. Queriers are not required to include the Deceased Date on query submissions.

11. Does the National Practitioner Data Bank (NPDB) accept licensure reports on non-physicians and non-dentists?

    No. The NPDB only accepts licensure reports on physicians and dentists. The Healthcare Integrity and Protection Data Bank (HIPDB) accepts licensure reports on all licensed practitioners.

12. A physician applying for appointment provided my healthcare organization with information about his claims history. When I compared that information to the results of our National Practitioner Data Bank (NPDB) query response, I could not find the Medical Malpractice Payment Report (MMPR) from the insurance company that the physician says settled a claim on his behalf. What should I do?

    As the querying healthcare organization, you should discuss the matter with the applicant for clarification. There are five reasons why this situation might occur:

    • The query may not have contained adequate information to match an existing report.
    • If the medical malpractice payment was made prior to the opening of the NPDB in 1990, it would not have been reported in the NPDB.
    • Although the physician might have been involved in the case, if no payment was made for his benefit, no report should have been filed.
    • If the practitioner was not named in both the claim and the settlement or judgment, no report should have been filed.
    • The reporting organization failed to file a required report.

    If you conclude that there should have been a report in the NPDB, which you did not receive, please alert us to this fact by calling the Customer Service Center at 1-800-767-6732. Information Specialists are available to speak with you weekdays from 8:30 a.m. to 6:00 p.m. (5:30 p.m. on Fridays) Eastern Time. The Customer Service Center is closed on all Federal holidays.

    We want to be sure the Data Banks contain all the reports that are required by law to be reported. For additional information regarding MMPRs, please see page E-8 of Chapter E of the NPDB Guidebook located on the Data Banks home page under the Publications category. (Also in Querying FAQ.)

13. My health plan made a $750,000 payment to the plaintiff to settle a medical malpractice lawsuit against two practitioners. The settlement was split as a $500,000 medical malpractice payment for the benefit of an internist and a $250,000 medical malpractice payment for the benefit of the cardiologist. Is my organization responsible for submitting one or two Medical Malpractice Payment Reports (MMPRs) to the National Practitioner Data Bank (NPDB)?

    Your health plan must submit two MMPRs to the NPDB because you are required to file a separate report for each practitioner when a payment is made for the benefit of, in settlement of, in satisfaction in whole or in part of, a claim or judgment against that practitioner. Each report must include the actual amount paid for the benefit of the named practitioner, as well as the total amount paid in the case, and the number of practitioners from whom it was paid. If the judgment or settlement does not specify an amount for each of the named practitioners, the reporter must allocate an amount to the named practitioners in each report as well as specify in each report the total amount paid for all practitioners and the number of practitioners for whom payment was made. If there is no other basis for allocating the total payment, the reporter may simply arbitrarily divide the total payment by the number of practitioners to determine the amount to report for each practitioner. In any event, the reporter must explain in the narrative the method used to allocate the payment. If the allocation was arbitrary, the reporter may explicitly state that the allocation was arbitrary and does not imply any determination as to the practitioner's degree of responsibility.

14. My organization, which requires its physicians to be board certified, denied a physician's application for surgical privileges because the physician was not board certified in a particular clinical specialty or subspecialty. Is this action reportable to the National Practitioner Data Bank (NPDB)?

    No, it is not reportable. If the healthcare organization's medical staff policy requires board certification, the automatic or administrative denial of medical staff membership or of a clinical privilege is not reportable.

    Adverse medical staff membership or clinical privileges actions, reportable to the NPDB, result from professional review actions relating to the practitioner's professional competence or professional conduct. (Also in Reporting FAQ.)

15. If the practitioner is not aware of a medical malpractice payment for his/her benefit is the payment reportable?

    Yes. There is no requirement that the practitioner for whom a medical malpractice payment is made receives notice of the claim, investigation, or payment. The fact that a payment was made for the benefit of a practitioner makes the payment reportable to the National Practitioner Data Bank (NPDB).

16. Are medical residents included within the definition of a physician?

    Yes. A medical resident is included within the definition of a physician if the resident is licensed or otherwise legally authorized by the State to practice medicine or surgery.

    The NPDB Guidebook, located on the Data Banks home page under the Publications category, provides advice for reporting and querying on residents. See page D-1 of the Queries chapter for information on querying and page E-1 of the Reports chapter for information on Reporting. (Also in Querying FAQ.)

17. A physician does not know that she is under investigation for possible professional incompetence and resigns from a hospital. Is the physician's resignation reportable to the National Practitioner Data Bank (NPDB)?

    Yes. Regardless of whether the practitioner was aware that an investigation was being conducted, a practitioner's resignation or surrender of privileges must be reported if the practitioner was under investigation at the time of the resignation or surrender. The reporting organization must be able to produce evidence that an investigation was ongoing at the time of the resignation or surrender to support the report if the practitioner challenges it. In addition, resignations and surrenders must be reported in situations in which the practitioner resigns or surrenders privileges after being notified that an investigation will be conducted, but before the investigation actually begins.

18. If a hospital reviews a surgeon's professional competence and assigns a surgical proctor for 60 days, and the surgeon cannot perform surgery without being granted approval by the surgical proctor or unless the proctor is physically present during the surgery. Is the action reportable to the National Practitioner Data Bank (NPDB)?

    Yes, since the surgeon cannot practice surgery without the approval or presence of the surgical proctor for 60 days, the action constitutes a restriction of clinical privileges in place for more than 30 days and must be reported to the NPDB.

19. Do I report a medical malpractice payment after making a low end payment under a high-low agreement?

    A payment made at the low end of a high-low agreement (that is in place prior to a verdict or an arbitration decision) should not be reported if the fact finder rules in favor of the defendant-practitioner. However, the payment is reportable if the fact finder rules in favor of the plaintiff or the agreement is not in writing.

20. In a medical malpractice lawsuit against a treating dentist and anesthesiologist, if the dentist is dismissed from the lawsuit before the settlement is made for the anesthesiologist, who should be reported to the National Practitioner Data Bank (NPDB)?

    The medical malpractice payment made for the benefit of the anesthesiologist is reportable. As to the dentist, if the dentist was dismissed from the lawsuit because a payment was made to settle the claim against him, the payment is reportable. However, no report is due, if the dentist was dismissed from the action independently without making a payment. (Also in Reporting FAQ.)

21. We are a medical malpractice payer that is making a payment based on claimant expenses only. Are claimant expenses reportable to the NPDB?

    Claimant expenses, referred to in the NPDB Guidebook as loss adjustment expenses (LAEs), are payments made for expenses other than those in compensation of injuries, such as attorney's fees, billable hours, expert witness fees, etc. Claimant expenses should be reported to the NPDB only if they are included in the medical malpractice payment. In which case, the expenses should be itemized in the description section of the Medical Malpractice Payment Report. If the claimant expenses are not included in the medical malpractice payment, or if a payment is only for claimant expenses, then they are not reportable to the NPDB. Please note: reporting requirements specify that the total amount of a medical malpractice payment and a description and amount of the judgment or settlement and any conditions, including terms of payment should be reported to the NPDB. (Also in Reporting FAQ.)

22. If a State medical board denies an application for license renewal because the physician did not pay his renewal fee by the deadline, is it a reportable adverse licensure action to the National Practitioner Data Bank (NPDB)?

    A denial of an application for license renewal, for failure to pay fees is generally not considered to be related to professional competence or conduct. However, if the particular State medical practice act identifies a failure to pay renewal fees as a matter of professional conduct, then it would be reportable.

23. What will my organization query response look like?

    The query response is a single response containing information on one or both Data Banks depending upon your organization's registration preferences. Each report included within the query response will appear only once and will indicate (with a checked box) if the report is maintained under Title IV (National Practitioner Data Bank [NPDB]), section 1921 (when approved and available), or section 1128E (Healthcare Integrity and Protection Data Bank [HIPDB]) statutes. (Also in HIPDB Querying and Reporting FAQs)