Credentialing How Tos   /   September 2019

A Quick Download on Reporting to NPDB

A Quick Download on Reporting to NPDB

Reporting to NPDB can be confusing – between knowing what to report, when to report it, and who is responsible for reporting, there is a lot to know. NCQA requires a number of primary sources be verified as part of the credentialing and re-credentialing process. In addition to verifying the state license, DEA license, education, and training, it is also critical to verify the contents of a provider’s NPDB file. We’ve collected all the most important information to make understanding this process as easy as possible. 

The National Practitioner Data Bank (NPDB) collects information regarding healthcare practitioners, healthcare entities, providers, and suppliers.  The information that is collected includes:

  • Medical Malpractice Payments
  • Licensure and certification actions both Federal and State
  • Adverse professional society membership actions
  • Negative actions or findings by private accreditation organizations and peer review organizations
  • Healthcare-related criminal convictions and civil judgments
  • Exclusions from participation in a Federal or State Health Care Program – this includes MediCare and MediCaid exclusions
  • Other adjudicated actions or decisions.

Under Title IV,  Medical Malpractice Payers (which includes self-insured hospitals and other healthcare entities) are required to report to NPDB. Also required to report are: state medical and dental boards, hospitals,  healthcare entities, professional societies with a formal peer-review process, the Drug Enforcement Administration (DEA), and the Department of Health and Human Services (HHS).

Medical malpractice payments are submitted to the NPDB and the State Licensing Board within 30 days of payment. Additionally, adverse licensure actions related to competence or conduct (including issues that affect clinical privileges) must be submitted within thirty 30 days of the action. This includes revocation, suspension, reprimand, censure, and probation. Voluntary surrender or restriction of clinical privileges while under investigation are also reported.  DEA restrictions are reported, as are exclusions from participation in federal healthcare programs.

California also requires an 805 report to be filed on physicians, surgeons, podiatrists, and physician assistants. There is often confusion around what exactly an 805 report is, so here is a breakdown in case you’ve been wondering.

An 805 report is required when: 

  1. a peer review body denies an applicant for staff privileges or membership due to a medical disciplinary reason, or if privileges have been revoked.
  2. If the provider has had restrictions imposed for a period of 30 days or more during a 12 month period
  3. if a summary suspension of staff privileges, membership or employment is imposed for a period in excess of 14 days, or if the provider resigns, withdrawals or abandons an application for renewal after receiving notice of a pending investigation.  An 805 report is to be filed within 15 days after the effective date of the action.

For more information on California’s specific rules and the 805 report, you can check out this website.

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