PIAA Corporate Counsel Workshop October 22 23, 2015

Transcription

1 PIAA Corporate Counsel Workshop October 22 23, 2015 Ernia Hughes, MBA Director, Division of Practitioner Data Bank Bureau of Health Workforce Health Resources and Services Administration U.S. Department of Health and Human Services Agenda NPDB History and Purpose Medical Malpractice Reports Other NPDB Considerations New NPDB Guidebook New NPDB Website Recent Activities Expanding Compliance Efforts Resources Questions 2 1

2 NPDB History And Purpose NPDB History and Purpose History Created in 1990 We re 25 this year! Initial statute: Title IV of Public Law Section 1921 of the Social Security Act and Section 1128E of the Social Security Act were added Section 1128E created the Healthcare Protection and Integrity Data Bank 4 2

3 NPDB History and Purpose Purpose Flagging system for effective credential review Protection against unfit practitioners Deter fraud and abuse in the health care system 5 NPDB History and Purpose 2013 Merger 6 HIPDB merged into NPDB all HIPDB data now available in NPDB Three substantive statutes remain Single query results in information previously found in two locations A single data bank with a single set of regulations Mandated by the Patient Protection and Affordable Care Act 3

4 How the Data Bank Works NPDB History and Purpose Report Reporting Entity CA NPDB TX Query Reports Queries Subject of Report Practitioner in CA Data Banks 7 Flag NPDB History and Purpose Information Collected Medical malpractice judgments, settlements Adverse licensing and certification actions Clinical privileges actions Health plan contract terminations Professional society membership actions Negative actions/findings from private accreditation organizations and peer review organizations Government administrative actions, e.g., exclusions from programs Civil and criminal health care related judgments 8 4

5 NPDB History and Purpose Data Bank Facts 1.21 million reports 79,000 new reports annually (including ~10,350 Medical Malpractice Payment Reports) Almost 5.5 million queries annually 18,000 registered organizations 48,000 users 9 Medical Malpractice Reports 5

6 Medical Malpractice Reports The Law Each entity (including an insurance company) which makes payment under a policy of insurance, selfinsurance, or otherwise in settlement (or partial settlement) of, or in satisfaction of a judgment in, a medical malpractice action or claim shall report... information respecting the payment and circumstances thereof. Title IV of Public Law Medical Malpractice Reports What This Means All malpractice payments in any amount made for the benefit of a health care practitioner must be reported to the NPDB Both settlements and judgments No dollar threshold for reporting Both Title IV and NPDB regulations recognize: A report does not mean that malpractice occurred, only that a payment was made 12 6

7 Medical Malpractice Reports To Be Specific... For a medical malpractice payment to be reportable to the NPDB, there must be: A payment made; For the benefit of a health care practitioner; Against whom a written medical malpractice claim or judgment was made; By a third party. 13 Medical Malpractice Reports A Written Claim The writing can take the form of a pre litigation written communication NPDB policy determines whether a written communication has occurred 14 7

8 Medical Malpractice Reports Reportable Payments Payments made for the benefit of a named practitioner by a professional corporation or other business entity comprised of a sole practitioner Payments made for deceased practitioners Payments made for licensed residents or interns, including those insured by their employers Any indemnity payment made for the benefit of a practitioner 15 Medical Malpractice Reports Non Reportable Payments 16 Medical malpractice payments made solely for the benefit of a corporation such as a clinic, group practice, or hospital A person, rather than a professional corporation or business entity, makes a payment out of personal funds Defendant health care practitioner is dismissed from the lawsuit before settlement or judgment and not as a condition in the settlement or release Practitioner named in the written claim, subsequently dismissed from lawsuit and not named in settlement release Practitioners not named or described in written demand or lawsuit 8

9 Medical Malpractice Reports Claims in Alternate Settings Claims raised in other adjudicative bodies, such as alternative dispute resolution or disclosure, apology and offer models are considered claims for the purposes of reporting, when they include a written demand from the patient for compensation. Standard of Care determinations are irrelevant for determining reporting requirements. 17 Medical Malpractice Reports Settlements in Other Adjudicated Actions 18 Settlements in which no findings or admissions of liability have been made are not reportable Actions that occur in conjunction with settlements in which no findings or admissions of liability have been made but that meet other NPDB reporting requirements must be reported 9

10 Medical Malpractice Reports Sanctions for Failing to Report Under Title IV of Public Law , any malpractice payer that fails to report medical malpractice payments is subject to a civil money penalty of up to $11,000 for each payment involved. 19 Medical Malpractice Reports No Querying Note that medical malpractice payers are not authorized to query the NPDB

11 Medical Malpractice Scenarios Medical Malpractice Scenarios Question 1: True or False: Medical Malpractice payments are limited to exchanges of money and must have resulted from a written complaint or claim demanding monetary payment for damages

12 Medical Malpractice Scenarios Answer 1: True. 23 Medical Malpractice Scenarios Question 2: True or False: Medical malpractice payers are eligible to receive information from the NPDB

13 Medical Malpractice Scenarios Answer 2: False. 25 Medical Malpractice Scenarios Question 3: True or False: A written claim can include the filing of a cause of action based on the law of tort in any state or federal court or other adjudicative body

14 Medical Malpractice Scenarios Answer 3: True. 27 Medical Malpractice Scenarios Question 4: To be reportable, a written complaint must be based on what? 28 14

15 Medical Malpractice Scenarios Answer 4: A practitioner s provision of or failure to provide healthcare services. 29 Medical Malpractice Scenarios Question 5: Who determines whether a written claim has occurred for purposes of filing a report? 30 15

16 Medical Malpractice Scenarios Answer 5: The NPDB 31 Medical Malpractice Scenarios Question 6: True or False: Subrogation type payments made by one insurer to another must always be reported to the NPDB

17 Medical Malpractice Scenarios Answer 6: False. 33 Medical Malpractice Scenarios Question 7: These expenses are those not related to the compensation of injuries, such as attorney fees, billable hours, copying costs, expert witness fees, and deposition and transcript costs

18 Medical Malpractice Scenarios Answer 7: Loss Adjustment Expenses. 35 Medical Malpractice Scenarios Question 8: True or False: If a defendant health care practitioner is dismissed from a lawsuit prior to settlement or judgment, for reasons independent of the settlement or release, a payment made to settle a medical malpractice claim or action should not be reported to the NPDB for that defendant health care practitioner

19 Medical Malpractice Scenarios Answer 8: True. 37 Medical Malpractice Scenarios Question 9: This kind of agreement is a contractual agreement between a plaintiff and a defendant s insurer that defines the parameters of a payment that the plaintiff may receive after a trial or arbitration proceeding

20 Medical Malpractice Scenarios Answer 9: High Low Agreement. 39 Medical Malpractice Scenarios Question 10: True or False: When a defendant practitioner has been found liable by a fact finder, any payment made for the practitioner s benefit must be reported, irrespective of any high low agreement

21 Medical Malpractice Scenarios Answer 10: True. 41 PIAA Contributions to Guidebook 21

22 PIAA Contributions to Guidebook Examples of Terminology Differences Asked for examples of when activities are reportable even though reporter uses different terminology that the Data Bank. Our Response We added examples of administrative fines and the suspension or restriction of clinical privileges. 43 PIAA Contributions to Guidebook Can a certifying official be an administrator? Asked for clarification of whether a Data Bank certifying official can be the same person as the Data Bank administrator. Our Response We clarified that the two positions can be filled by a single individual

23 PIAA Contributions to Guidebook Definition of Initial Report Asked that the definition of an Initial Report be clarified and simplified. Our Response We made the definition more straightforward: The first report of a medical malpractice payment, adverse action, or judgment or conviction submitted to and processed by the NPDB is considered the Initial Report. 45 PIAA Contributions to Guidebook How can health plans use NPDB info? Asked whether health plans can use NPDB information in civil actions against practitioners, providers, or suppliers. Our Response We reorganized the chapter on NPDB queries and, in doing so, clarified when health plans can query the NPDB and the type of information they receive

24 PIAA Contributions to Guidebook When should practitioners named in a release be reported to the Data Bank? Suggested this language: Practitioners identified in the release but not in the written demand or as defendants in the lawsuit should not be reported to the NPDB. Our Response We accepted the language suggestion. 47 PIAA Contributions to Guidebook When is an unnamed practitioner sufficiently described to be reportable? Asked for definition and examples of what sufficiently described... So as to be identifiable means for reporting purposes. Our Response We added examples of when a practitioner is sufficiently identified without being specifically named

25 PIAA Contributions to Guidebook When must practitioner, dismissed from a lawsuit, be reported to the NPDB? Suggested that draft language left too much room for interpretation. Our Response We added language saying that a defendant dismissed for reasons independent of the settlement or release should not be reported to the Data Bank. 49 Other NPDB Considerations 25

26 Other NPDB Considerations Types of Transactions Reporting (no charge) Querying (by health care organizations, state and federal agencies, professional organizations) $3 for 1 year continuous query subscription $3 for a one time query Fees lowered October 1, 2014 Self query (by an individual or organization $5 51 Fee lowered October 1, 2014 Other NPDB Considerations Continuous Query 52 Subscription service notifies subscribers of new information on any enrolled practitioner Designed and developed to help meet new accreditation standards that require ongoing monitoring of practitioners Since 2007, providers have enrolled more than 1.85 million practitioners 26

27 Other NPDB Considerations Comparing One Time & Continuous Query One Time Query Average of 320 days between receipt of a report and disclosure of the report (in response to a query) Re credentialing means requerying practitioners and reviewing all results to identify new information Continuous Query Service notifies subscribers of a report on enrolled practitioners within 1 day of receipt Subscriber organizations always up to date Subscribers can deal only with events that need attention, immediately resolving issues 53 Other NPDB Considerations Using Continuous Query 54 Requires same practitioner information Subscribers continue using their subject databases Fee: $3.00 per enrollee per year No separate query fee Upon enrollment, receive the same report information as a one time query response Notifies subscribers of any new reports No need to re query for reappointments or temporary privileges extensions 27

28 Other NPDB Considerations Using Continuous Query, continued Notification sent via ; subscriber must log in to retrieve information Subscription period for each enrollee is 12 months Subscription expires on the last day of the same month the following year Subscription started in December 2014 will expire on December 31, Other NPDB Considerations Continuous Query Endorsements The Joint Commission National Committee for Quality Assurance (NCQA) Commission on Accreditation of Rehabilitation Facilities (CARF) Utilization Review Accreditation Commission (URAC) Centers for Medicare and Medicaid Services (CMS) Using Continuous Query helps meet obligations imposed by the Health Care Quality Improvement Act of 1986 (HCQIA) 56 28

29 Other NPDB Considerations General Provisions Recovering costs NPDB must recover the full cost of operations Confidentiality Information reported to the NPDB: Confidential Not available to the general public May only be disclosed as provided by law Penalty of up to $11,000 per violation 57 Other NPDB Considerations Civil Liability Protection 58 Immunity provisions in Title IV, Section 1921 and Section 1128E protect individuals, entities, and their authorized agents from being held liable in civil actions for reports made to the NPDB unless they have actual knowledge that the information in the report is false Health care entity professional review bodies, their members, and their agents are immune from civil liability in most cases 29

30 Other NPDB Considerations Querying and Reporting Different types of entities have different querying and reporting obligations For example, hospitals are the only entities required by NPDB law to query the NPDB Here s a look at the requirements Who Reports and Queries?

31 Total NPDB Reports, ,000 40,000 35,000 30,000 25,000 20,000 Adverse Action Reports Medical Malpractice Payment Reports 15,000 10,000 5, Report Subjects by Profession,

32 Entity Perceptions Hospital All Other Entities Non Negative Negative Very Negative N/A How entities perceive health care practitioners with Medical Malpractice Payment Reports Source: 2014 NPDB Users Survey Practitioner Perceptions Doctor Types Other HCP Non Negative Negative Very Negative N/A How practitioners think entities view practitioners with MMPRs Source: 2014 NPDB Users Survey 32

33 New NPDB Guidebook New NPDB Guidebook Revision Process Revised a policy manual last updated in 2001 Released draft NPDB Guidebook for comment in November 2013 Received 360 comments Final version released April 6, 2015 Available formats: Printable and searchable PDF Web based version, with search 66 33

34 New NPDB Guidebook 67 New NPDB Guidebook 68 34

35 New NPDB Guidebook The More Things Change... What the new Guidebook does Blends Healthcare Integrity and Protection Data Bank and NPDB to reflect new combined regulations Adds Section 1921 Provides policy clarification What the new Guidebook does NOT do Make revisions that require legislative or regulatory changes Accept or address every recommendation made by commenters 69 New NPDB Guidebook Key Changes Eligible Entities Definition of Other Health Care Entity Registration requirements (use of DBIDs, User IDs) Subjects of Reports Definitions of health care practitioners, providers, and suppliers 70 35

36 New NPDB Guidebook Key Changes, continued Queries Centralized vs. decentralized credentialing Delegated credentialing vs. using an agent Clinical vs. non clinical privileges Reports Submitting reports Corrections vs. revisions Appeals 71 New NPDB Guidebook Key Changes, continued Reporting Medical Malpractice Payments Oral vs. written claims Identifying practitioners Reporting Adverse Clinical Privileges Actions Summary suspensions Proctors 72 36

37 New NPDB Guidebook Key Changes, continued Investigations Definition of term is not controlled by entity s bylaws Routine review of a practitioner is not an investigation Focus on a particular practitioner Precursor to professional review action Ongoing until decisionmaking authority takes final action 73 New NPDB Guidebook Key Changes, continued Reporting Licensure and Certification Actions Administrative fines Summary/emergency suspensions Stayed actions Denials Withdrawals and failure to renew while under investigation Voluntary surrenders 74 37

38 New NPDB Website New NPDB Website Launched June 1 Easier to navigate home page New look and feel Content organized in three main categories: For Health Care Professionals For Organizations NPDB Resources Reaction so far: positive 76 38

39 New NPDB Website More Changes Coming 77 Adding carousel of photos to home page Each entity type will have own page, with all needed information in one spot Revising pulldown menus for clarity Incorporating standalone content (such as Administrator s Handbook) as web pages Expanding and revising content throughout the site We re open to suggestions! Recent Activities 39

40 Recent Activities Active Speaking Schedule Participated in more than 15 webinars and inperson talks this year Many were general education sessions, getting word out about the NPDB Some were specific to the NPDB Guidebook lawyers and NPDB users had questions about the publication 79 Recent Activities Education Forum Held in Gaithersburg, MD, in April A multimedia event associated with release of customer support videos Offered technical training on Reporting Querying Research applications NPDB Guidebook System updates 80 40

41 Expanding Compliance Efforts Expanding Compliance Efforts 82 On the Menu Until now, focused primarily on licensing boards Licensing boards process updated in July 2015 Shifting attention to other areas Community health centers Hospitals Health plans Medical malpractice payers Focus on improving NPDB registration data and overall data integrity 41

42 Expanding Compliance Efforts Steps Involved Identify universe of entities Are entities registered? Reporting? Querying? Contact entities Explain NPDB obligations Work on issues that arise Set up periodic verification process 83 Expanding Compliance Efforts Looking for Advice How do we best reach malpractice payers? Our tasks: Identify universe of payers See if payers are registered, reporting Explain NPDB obligations Work on issues that arise Set up periodic verification process 84 42

43 Resources Resources Website FAQs, brochures, and fact sheets NPDB Guidebook Recorded webinars Instructions for reporting and querying Regulations Statistical data Research tools NPDB News 86 43

44 Resources Customer Service Center Call Questions? 88 44

45 Contact Information Ernia Hughes, MBA Director, Division of Practitioner Data Bank Bureau of Health Workforce Health Resources and Services Administration U.S. Department of Health and Human Services Telephone: