A holistic approach to exclusion monitoring and license verifications must include monitoring of disciplinary databases such as the National Practitioner Data Bank (NPDB). Integrating NPDB continuous query into your monitoring process ensures a complete view of your credentialed population and allows you to manage, monitor, and verify your providers in one place – saving you time and ensuring peace of mind.
In this quick guide, we’ll explore the importance of including NPDB monitoring in your routine license and exclusion monitoring to protect your organization and the patients you serve from fraud, waste, and abuse.
What is the National Practitioner Data Bank (NPDB)?
The National Practitioner Data Bank (NPDB) is a confidential information clearinghouse operated by the U.S. Department of Health and Human Services (HHS) and contains medical malpractice payments and adverse action reports on healthcare professionals. Its mission is to enhance healthcare quality, defend the public, and decrease healthcare fraud and misuse in the U.S.
Established by the Healthcare Quality Improvement Act of 1986 (HCQIA), the NPDB protects the public by restricting practitioners’ ability to move around without disclosing medical malpractice payments or adverse action histories. This prevents practitioners from moving from state to state or hospital to hospital with a hidden record.
During the time of credentialing, employment, licensing, or monitoring, the NPDB serves as an alert or flagging system intended to facilitate a comprehensive review of healthcare practitioners’ professional credentials. The information contained in the NPDB directs discrete inquiry into, and scrutiny of, a practitioner’s licensure, clinical privileges, professional society memberships, and medical malpractice payment history.
Healthcare Legislation & Regulations
Federal legislation and regulations are the foundation of the National Practitioner Data Bank (NPDB). Below are the significant laws and regulations that govern NPDB operations:
- NPDB Regulations
- NPDB Eligible Entities
- Subpart B—CMPs, Assessments, and Exclusions for False or Fraudulent Claims and Other Similar Misconduct
- Subpart C—CMPs, Assessments, and Exclusions for Anti-Kickback and Physician Self-Referral Violations
- Subpart E—CMPs and Exclusions for EMTALA Violations
- Subpart J—CMPs, Assessments, and Exclusions for Beneficiary Inducement Violations
Who Can Search the NPDB?
The NPDB is prohibited by law from disclosing information on a specific practitioner, provider, or supplier to the general public. However, hospitals, state licensing boards, professional societies, other healthcare-eligible entities, and plaintiffs’ attorneys are permitted to query the NPDB under specific conditions.
Also, individuals may query their own records. Hospitals are the only healthcare entities with a mandatory requirement for querying the NPDB. During the employment process (and every two years), a hospital must request information on prospective healthcare practitioners.
The NPDB is unique in that it is a sourced databank. Participating entities report individuals directly to the NPDB, who are then added to the list of providers. The NPDB strictly limits access by designated entities due to the extent and much more sensitive nature of the data maintained. According to the NPDB, “to query on behalf of a healthcare organization, a registered organization must be given the authority to query and/or report to the NPDB on their behalf.”
ProviderTrust is registered as an “authorized agent” and can be found on the NPDB’s directory of Authorized Agents.
Healthcare Exclusion and Sanction Monitoring
As a reminder, exclusion screenings are conducted to verify that a potential employee is not classified as an excluded individual who has been excluded from participation in any federal healthcare program. A healthcare sanction is an administrative action taken against an individual or a state professional licensure board license. Such sanctions can be attributed to a restriction placed upon a license and can include a revocation of the license.
Healthcare organizations must have a comprehensive plan to screen their providers and affiliates against various exclusion lists. This should be done at least at the time of employment and once a month thereafter.
The best practice for finding exclusions and sanctions in addition to referencing the NDPB is to search the OIG LEIE and SAM.gov websites and all available state Medicaid exclusion lists. This practice will ensure that you are not employing or contracting with an excluded person or entity.
We’ve made it easy to reference healthcare exclusion data all from one convenient location. Check out our interactive exclusion map to see how many exclusions are present from the OIG LEIE, SAM.gov, and all state Medicaid excluded, sanctioned, or terminated provider lists.
