Type of Action NPDB Reporting Format
Other adjudicated actions or decisions taken by
a Government agency Government Administrative Action on the
Adverse Action Report format Other adjudicated actions or decisions taken by
a health plan Health Plan Action on the Adverse Action
Report format
Other Adjudicated Actions or Decisions Taken in Conjunction with Clinical Privileges Actions
Certain Federal and State agencies and health plans that are required to report other adjudicated actions or decisions also may be required to report clinical privileges actions if those actions meet NPDB reporting requirements. However, because the definition of other adjudicated actions or decisions specifically excludes clinical privileges, if an entity takes both a clinical privileges action and another adjudicated action or decision, the entity must report them separately.
E-101
NPDB Guidebook Chapter E: Reports
April 2015
For example, if a health plan takes a network participation action that meets the NPDB reporting requirements for an adverse clinical privileges action in conjunction with a contract termination that meets the definition of an “other adjudicated action or decision,” each action must be reported separately. When submitting these actions to the NPDB, the health plan must submit two reports: the health plan must report the network participation action as a Clinical Privileges Action on the NPDB’s Adverse Action Report format; in addition, it must report the contract termination (which is another adjudicated action or decision) as a Health Plan Action on the Adverse Action Report format.
Sanctions for Failing to Report to the NPDB
If HHS determines that a Federal agency, a State law enforcement agency, a State Medicaid fraud control unit, or a State agency administering or supervising the administration of a State health care program has substantially failed to report information required to be reported to the NPDB, the name of the entity will be published and made publicly available.
Any health plan that fails to report information on an adverse action required to be reported to the NPDB will be subject to a civil money penalty of up to $25,000 for each such adverse action not reported. Such penalty will be imposed and collected in the same manner as civil money penalties under Section 1128A(a) of the Social Security Act.
Q&A: Reporting Other Adjudicated Actions or Decisions
1. A Federal hospital terminated the employment of one of its nurses after an investigation determined that the nurse had physically and verbally abused several patients. The nurse was afforded due process. Should this action be reported to the NPDB?
Yes. Federal agencies must report other adjudicated actions or decisions to the NPDB. The Federal hospital meets the definition of a Federal agency, and the employment termination meets the definition of another adjudicated action or decision. Other adjudicated actions or decisions must be formal or official final actions taken against a health care practitioner, provider, or supplier that are related to the delivery of a health care item or service and include the availability of a due process mechanism.
2. A health plan terminated contracts with several psychologists in its network because the plan determined it already had too many
psychologists in that geographic area. Should this action be reported to the NPDB?
E-102
April 2015
No. While health plans are required to report actions that meet the definition of an “other adjudicated action or decision,” that definition specifically excludes business or administrative decisions by health plans that result in contract terminations unrelated to health care fraud, or abuse, or quality of care issues.
The contract terminations taken by this health plan were based on the health plan’s business decisions regarding its network and were not related to health care fraud, or abuse, or the quality of health care delivered by the practitioners involved.
3. A health maintenance organization (HMO) terminated the contract of one of its physicians for sexually harassing a nurse. The HMO also took a professional review action to revoke the physician’s network participation.
The HMO’s standard operating procedures require that practitioners be afforded due process when contract actions are taken for cause. The standard operating procedures also require a committee of peers to make all network participation determinations. What should be reported to the NPDB?
The HMO must submit two separate reports to the NPDB. The contract
termination must be reported to the NPDB because it meets the definition of an
“other adjudicated action or decision.” The HMO should report the contract termination as a Health Plan Action on the NPDB’s Adverse Action Report format. The HMO also should separately report the revocation of network participation to the NPDB because it is a professional review action based on the physician’s professional competence or conduct. This action should be reported as a Clinical Privileges Action on the Adverse Action Report format.
NPDB governing laws and regulations require that clinical privileges actions (including network participation) and other adjudicated actions or decisions be reported to the NPDB separately.
4. A health care entity terminated a physician’s contract for causes relating to poor patient care, which in turn resulted in loss of the practitioner’s
network participation. Should this be reported to the NPDB using one or two reports?
Depending on the circumstances, the health care entity may be required to submit two different reports. The loss of the practitioner’s network participation that resulted from the termination of the contract for reasons relating to
professional competence or professional conduct must be reported as a clinical privileges action only if it is considered to be a professional review action by the health care entity.
E-103
NPDB Guidebook Chapter E: Reports
April 2015
The termination of the practitioner’s contract with the health care entity, in itself, does not meet NPDB reporting criteria for a clinical privileges action.
However, if the contract termination meets the definition of an “other adjudicated action or decision,” the contract termination should be reported separately to the NPDB.
5. After an investigation and formal hearing, a State hospital suspended without pay one of its physician employees after discovering that the physician had misrepresented his credentials on his employment application. Is this reportable?
Yes. Certain State agencies, including State agencies administering State health care programs, must report other adjudicated actions or decisions to the NPDB.
Other adjudicated actions or decisions are formal or official final actions taken against a health care practitioner, provider, or supplier that are related to the delivery of a health care item or service and that include the availability of a due process mechanism.
6. A health plan determines that a pharmacy had been improperly
substituting generic compounds for certain prescribed brand-name drugs and terminates the pharmacy’s contract. While reaching its decision, the health plan employed the due process safeguards it had set in place. Is the termination reportable?
Yes. The action taken by the health plan is a reportable adjudicated action because it was taken against a health care practitioner, provider, or supplier, included the availability of due process, and was related to the delivery of health care items or services.
7. After he disclosed conduct to the OIG as part of a settlement agreement, a physician agreed to pay $30,000 for allegedly violating the Civil Monetary Penalties Law. The physician disclosed that he employed an individual who he knew or should have known was excluded from participation in Federal health care programs. The settlement did not involve a finding or
admission of liability. Should this be reported to the NPDB as an other adjudicated action or decision?
No. Settlements in which no findings or admissions of liability have been made are statutorily excluded from being reported to the NPDB. Therefore, the OIG should not report the payment made as part of a settlement in which there was no finding of liability. However, if the OIG had taken an action in conjunction with this settlement and that action otherwise met NPDB reporting
E-104
April 2015
requirements (e.g., an exclusion from participation in Federal health care programs), that action must be reported.
8. The OIG pursued civil money penalties against a hospital for allegedly failing to provide an appropriate medical screening examination and stabilizing treatment. The patient was told to go home and follow orders from his primary care provider. Two days later, the patient went to another hospital’s emergency department, was admitted to the intensive care unit, and then died due to H1N1 influenza. The first hospital agreed to pay $25,000 to settle its liability for civil money penalties under the
Emergency Medical Treatment and Active Labor Act. The settlement did not include any findings or admission of liability by the hospital. Should this action be reported?
No. Settlements in which no findings or admissions of liability have been made are statutorily excluded from being reported to the NPDB. Therefore, the OIG should not report the payment made as part of a settlement in which there was no finding of liability. However, if the OIG had taken an action in conjunction with this settlement, and the action otherwise met NPDB reporting requirements (e.g., an exclusion from participation in Federal health care programs), that action must be reported.
9. The OIG pursued civil money penalties against a physician because the physician and his medical practice allegedly billed Medicare improperly.
The physician appealed the decision to impose a civil money penalty to the HHS Departmental Appeals Board. The administrative law judge assigned to the case found in favor of the OIG and upheld the imposition of the civil money penalty against the physician. Should these money penalties be reported?
Yes, the civil money penalties should be reported as other adjudicated actions or decisions because they are formal or official actions taken against a health care practitioner by a Federal agency that include the availability of a due process mechanism and were based on acts or omissions that affect or could affect the payment of health care services.
E-105
NPDB Guidebook Chapter F: Subject Statements and the Dispute Process
April 2015