HIPDB: Reporting Responsibilities Federation of Chiropractic Licensing Boards 81 st Annual Congress May 4, 2007 LCDR Shari W. Campbell, DPM, MSHS U. S.

HIPDB: Reporting ResponsibilitiesFederation of Chiropractic Licensing Boards

81st Annual Congress

May 4, 2007

LCDR Shari W. Campbell, DPM, MSHSU. S. Department of Health and Human ServicesHealth Resources and Services AdministrationBureau of Health ProfessionsPractitioner Data Banks Branch

Overview

HIPDB Background Report Data Compliance Activities System Improvements New Initiatives

HIPDB

Background

HIPDB Purpose

The intent is to protect the public, improve the quality of health care and deter fraud and abuse in the health care system by providing information about past adverse actions of practitioners, providers, or suppliers to authorized health care entities and agencies.

HIPDB BackgroundHIPDB Background

Established through Section 1128E of the Social Security Act as amended by Section 221(a) of Public Law 104-191, the Health Insurance Portability and Accountability Act of 1996 (HIPAA)

Final regulations governing the HIPDB are codified at 45 CFR Part 61

All final adverse actions taken on or after August 21, 1996 must be reported

By Law, Who Must Report?

State Government Entities Federal Government Entities Health Plans

Who May Query the HIPDB?

Federal and State Government Agencies Health Plans Health Care Providers, Practitioners and

Suppliers (self-query only) Researchers (non-identifiable statistical

information)

Who is Reported?

Health Care ProvidersExamples: Hospitals, Health Plans, PPOs, Medical Group

Practices Health Care Practitioners

Examples: Chiropractors, Podiatrists, Athletic Trainers, Registered Nurses, Certified Nurse Assistants

Health Care SuppliersExamples: Durable Medical Equipment Suppliers,

Pharmaceutical Suppliers and Manufacturers, Billing and Transportation Service Suppliers

What is Reportable?

Federal and State licensing and certification agencies must report final adverse actions* that are taken against health care: Providers Practitioners Suppliers

*Regardless of whether the final adverse action is the subject of a pending appeal

What is Reportable?

Licensing and certification actions: Revocation, Suspension, Probation, Censure,

Reprimand Any other loss of license or certification, or right to

apply for, or renew a license whether by voluntary surrender, or non-renewal

Any other negative action or finding that is publicly available information

What is Reportable?

Criminal Convictions Federal and State Prosecutors must report criminal

convictions* related to the delivery of a health care item or services

Civil Judgments Federal and State attorneys and health plans must report civil

judgments* related to the delivery of a health care item or services

Exclusions Federal and State Government agencies must report health

care providers, suppliers, or practitioners excluded* from participation in Federal or State health care programs

*Regardless of whether the conviction is the subject of a pending appeal

What is Reportable?

Other Adjudicated Actions Federal and State government agencies and

Health Plans must report other adjudicated actions, * which are defined as:

Formal or official final actions taken against health care practitioners, providers, or suppliers, which include the availability of a due process mechanism; and

Are based on acts or omissions that affect or could affect the payment, provision, or delivery of a health care item or service

*Regardless of whether the exclusion is the subject of a pending appeal

What is not Reportable?

Medical Malpractice Payments Settlements in which no findings or admissions

of liability have been made Temporary Actions; i.e. summary or emergency

HIPDB

Data

What is in the HIPDB?Practitioner Reports

18%

76%

1%

4%

1%

0%

State Licensure 193,910

State & Fed Exclusions 45,827

Judgments or Convictions 10,693

Gov't Admin 2,283

Health Plan 3,626

DEA 468

Cumulative Data as of 12/31/06

What is in the HIPDB?Practitioner Reports

8%8%

82%

2%0%

0%State Licensure 28,207

State & Fed Exclusions 2,916

Judgment or Conviction 2,595

Health Plan 529

Gov't Admin 120

DEA 23

Reports received in 2006

What is in the HIPDB?Organizations

26%

9%

3%

2% 0%

60%

State Licensure 2,061

State & Fed Exclusions 711

Judgments or Convictions 266

Gov't Admin 4,805

Health Plan 159

DEA 15

Cumulative Data as of 12/31/06

What is in the HIPDB?Organizations

14%

7%

4%

1%

1%

73%

State Licensure 197

State & Fed Exclusions 104

Judgment or Conviction 57

Health Plan 20

Gov't Admin 1,032

DEA 15

2006 Data

HIPDB QUERIERS

Self-Queries 5.7%

Gov't Hospitals 15.6%

Health Plans 64%

Government HealthProg 1.2%State Boards 8%

Other ServiceProviders 5%

8%

5%

2006 Data

64%

15.6%

5.7%

1.2%

Types of Reports on Chiropractors

2004 2005 2006 Total # of Reports

Licensure 184 309 1135 1628

Malpractice 235 213 208 656

Exclusions 134 48 69 251

Health Plan 111 128 96 335

JOCR 15 10 18 43

Clinical Privileges

6 5 13 24

Note: Data represents the date that the action was submitted to the NPDB or HIPDB

Types of Reports on Chiropractors

0

200

400

600

800

1000

1200

2004 2005 2006

LicensureMalpracticeExclusionsHealth PlanJOCRClin Priv

Note: Data represents the date that the action was submitted to the NPDB or HIPDB

Number of Reports

Chiropractor Licensure Actions

0%

20%

40%

60%

80%

100%

Reported2004

Reported2005

Reported2006

Action Taken 2006Action Taken 2005Action Taken 2004Action Taken 2003

HIPDB

Compliance Activities

Compliance Activities

Convey the importance of timely reporting Holding Policy Forums and talking with leadership of composite State

licensing boards Presenting to Associations/Federations of State licensing boards Presenting to State Association Medical Staff Services

Regulations Mandates reporting within 30 days of the date of the final action. NPDB: Title IV of Public Law 99-660, the Health Care Quality

Improvement Act of 1986, as amended and its implementing regulations (45 CFR Part 60)

HIPDB: Section 1128E of the Social Security Act as added by Section 221(A) of the Health Insurance Portability and Accountability Act of 1996 and its implementing regulations (45 CFR Part 61)

Compliance Activities

Monitor Timely Reporting Compare actions documented on State Licensing Board web sites to

actions reported to the NPDB and/or HIPDB Identify and contact States that have not reported any actions to the

NPDB and/or HIPDB Search other publicly available information for actions and payments

that should have been reported Review reports that are filed and later voided

Review a limited number of report narratives to determine if they are legally sufficient: Must include enough information so that future queriers knowing

nothing about the events giving rise to the report will have an understanding of what the subject practitioner is alleged to have done, the nature of the action taken and the reasons for the report

Compliance Activities

Compare NPDB payment reports to the NAIC summary payment reports (Supplement A to Schedule T)

Review Medical Malpractice Payment Reports that mention High-Low agreements in the narrative to determine if the payment was made for the benefit of the: Practitioner (reportable) Insurer to avoid the risk of a higher payment when the finder of fact

ultimately determines that the practitioner had no liability (not reportable) These reporters are asked to void the report

Monitor the eligibility of Data Bank Registrants Monitor for violation of Confidentiality Rules

HIPDB

System Improvements

June 18, 2007 System Release

Ability to correct a Revision-to-Action Report (IQRS and ITP) Ability to update a Subject Address when entering a Dispute

Statement or Secretarial Review Request Increase all Report Narratives and Subject Statements to

4,000 Characters Enhanced ITP Client Program for Password Encryption

New version will be posted on the informational website and available for download as of April 30, 2007

New version must be used on June 18 - previous version will not work

June 18, 2007 System Release

Display most recent Entity Information Section A will be expanded to include the most recent reporter name

and address (if it has changed) since the submission date Five variations

No change in reporter information Updated reporter information Original reporter is inactive with no successor Original reporter is inactive with a successor Original reporter is inactive with a successor, the successor is

inactive

No change

Reporter information is currentReporter information is current

Original Reporter inactive with no Successor

Reporter is inactive with no successorReporter is inactive with no successor

Original Reporter inactive with a Successor

Reporter is inactive with a successorReporter is inactive with a successor

Successor POC is provided if presentSuccessor POC is provided if present

Original Reporter inactive with a Successor

Reporter is inactive with a successorReporter is inactive with a successor

Successor POC is provided if presentSuccessor POC is provided if present

Original Reporter inactive with a Successor, and the Successor is also

inactive

Reporter is inactive with a successor, and the successor is also inactive

Reporter is inactive with a successor, and the successor is also inactive

Successor POC is provided if presentSuccessor POC is provided if present

June 18, 2007 System Release

Limit Registration Renewal Grace Periods There will be a limit of three months or four (4) grace renewals, whichever

is longer, in which the entity is permitted access to the system without actually renewing

Once the limit is passed, the system will permit the user to renew only. There will not be a grace period provided to use the system while the renewal is mailed and processed

Grace Period For Expired Entity Registrations The system considers an entity to be “inactive” once their registration

expires. Report change notifications are not sent to inactive entities To prevent an entity with an expired registration from missing report

change notifications, a 90 day grace period will be established

June 18, 2007 System Release

Addition of another option to Automatic Reinstatement Data Element (IQRS and ITP)

Currently, an entity can select only "yes" or "no" in response to whether a reinstatement is automatic at completion of the adverse action period Add a third response option:

Yes Yes, with conditions (requires a Revision to Action Report when status

changes) No

Automatic Reinstatement Options

Now three response options

Now three response options

Other Recent System Improvements

Historical Summaries Users can retrieve historical summaries of their queries and reports back to

June 2000. Use entity name and specific date range for the search Limited to one-year increments within three years of the search date

Query/Report Response Availability Available via IQRS for 45 days, previously only available for 30 days

Timely Reporting Notice regarding timeliness of reporting included on the Report Verification

Document (RVD)

NPDB - HIPDB

New Initiatives

Proactive Disclosure Service (PDS)Section 1921: expansion of the NPDB

Proactive Disclosure Service (PDS)

The intent of PDS is to protect the public and improve the quality of health care by providing information to entities as soon as it is received by the Data Banks Average querier receives a new Data Bank report in 302

days Opens as a Prototype on May 1, 2007

Prototype status expected to last 18 months for evaluation purposes

The Current Query Process

Hospitals, other health care entities, including MCOs, State and Federal agencies query the Data Bank by requesting information on a routine schedule

A seamless, secure internet system permits a user to query one or both Data Banks

Users query in preparation for reappointment or during the re-credentialing process (typically every 2 or 3 years)

The query fee is $4.75 per name, per Data Bank

The PDS Process

A subscription service that notifies subscribers of new information on any of their enrolled practitioners within one business day of Data Banks receipt of the information

Notification is sent via email; the entity must log in to retrieve the information

Offered as an alternative to and not a replacement of the current querying method

Report format, information and data reported to the Data Banks will not change

Can use PDS for NPDB, HIPDB or both Fee is $3.25 per enrolled subject / per year

PDS Enrollment

Enrollment Confirmation: An enrollment confirmation confirms that a

practitioner is enrolled in the PDS May be used to demonstrate compliance

with accreditation standards

Enrollment confirmations include Subject information PDS enrollment dates, and Enrollment status

PDS Enrollment

When a practitioner is first enrolled in the PDS, the enrollment confirmation will include all reports on the practitioner to ensure the entity is aware of all existing reports in the Data Banks

This is included in the price of PDS

Enrollment confirmations for enrolled practitioners and previously enrolled practitioners whose enrollments have been cancelled within the last four years will be available, upon demand

Report NotificationEntity receives email notification

Entity receives email notification

Report Notification

Report Notification

Report Notification

Users always have access to all the active reports on a subject

Users always have access to all the active reports on a subject

Report Notification

Other PDS Characteristics

Data Bank report availability:

Report disclosures will be available on the IQRS for 45 days in PDF format

All reports in the Data Banks for each enrolled practitioner will be available upon demand

Other PDS Characteristics

Subscribing to the service:

A 12-month subscription period for each enrollee (practitioner)

The subscription expires on the last day of the same month of the following year

i.e., all practitioners enrolled in May 2007 regardless of the exact date of enrollment will have a subscription expiration date of May 31, 2008

Section 1921

A provision of the Social Security Act as amended by Section 5(b) of the Medicare and Medicaid Patient and Program Protection Act of 1987, as amended by the Omnibus Budget Reconciliation Act of 1990.

Enacted to provide protection to program beneficiaries from questionable health care practitioners and to improve the anti-fraud provisions of Medicare and Medicaid.

Section 1921

Notice of Proposed Rule Making Published in the Federal Register on March 21,

2006 Expected final in October 2007 Expands the NPDB

Major reports Added by Section 1921 Adverse actions or findings by private accrediting

organizations such as: NCQA URAC The Joint Commission The Commission on Accreditation of

Rehabilitation Facilities

Section 1921

Adverse licensure actions taken against all health care practitioners

Broader than issues related to professional competence and conduct

Adds the same type of licensure actions currently reported to the HIPDB

Reportable: without Section 1921

NPDB Medical Malpractice Payments Adverse Actions (physicians and

dentists) Licensure Clinical Privileges* Professional Society

Membership* Medicare and Medicaid Exclusions (all

practitioners) DEA Actions (all practitioners)*other practitioners may be reported

HIPDB* Licensure Actions Medicare and Medicaid Exclusions

and other exclusions from Federal or State Health Care Programs

Health Care Related Criminal Convictions, or Civil Judgments

Other Adjudicated Actions or Contract Terminations

*Practitioners, Providers and Suppliers

Reportable: with Section 1921

NPDB Medical Malpractice Payments Adverse Actions (physicians and

dentists) Licensure Clinical Privileges* Professional Society

Membership* Medicare and Medicaid Exclusions (all

practitioners) DEA Actions (all practitioners)*other practitioners may be reported

HIPDB* Licensure Actions Medicare and Medicaid Exclusions

and other exclusions from Federal or State Health Care Programs

Health Care Related Criminal Convictions, or Civil Judgments

Other Adjudicated Actions or Contract Terminations

*Practitioners, Providers and Suppliers

Section 1921

Access Entities that are currently allowed to

query the NPDB will have access to Section 1921 reports

Entities given access to the NPDB through Section 1921 will be allowed to query ONLY for Section 1921 reports

Access without Section 1921

NPDB Hospitals and other Health Care

Entities State Medical and Dental

Licensing Authorities Professional Societies with

formal peer review Practitioners (self-query only) Researchers (non-identifiable

statistical information)

HIPDB Federal and State

Government Agencies Health Plans Practitioners, Providers and

Suppliers (self-query only) Researchers (non-identifiable

statistical information)

Access with Section 1921

NPDB & Section 1921 Hospitals and other

Health Care Entities State Medical and Dental

Licensing Authorities Professional Societies

with formal peer review Practitioners (self-query

only) Researchers (non-

identifiable statistical information)

Section 1921 Only State Medicaid Fraud

Control Units Agencies administering

Federal and State Health Care Programs

U.S. Comptroller General U.S. Attorney General

and other law enforcement officials

Reference Information

Web Site - www.npdb-hipdb.hrsa.gov NPDB and HIPDB Guidebooks Interactive Training Brochures and Fact Sheets Statistics Annual Reports Instructions for Reporting and Querying

Customer Service Center - 1-800-767-6732 (1-800-

SOS-NPDB)

LCDR Shari W. Campbell, DPM, MSHSPolicy Analyst

Practitioner Data Banks Branch(301) 594-4251

[email protected]

Contact Information