NPDB Insights - May 2021

Is It Reportable?

A board of medical examiners initiated an investigation related to a physician's professional conduct. Two weeks later, the physician allowed his license to expire. The physician's license lapsed prior to any proposed agreement or board decision, so must the lapse be reported to the NPDB?

Yes. A nonrenewal of a license while under or to avoid an investigation must be reported to the NPDB.

Step-by-Step: Reporting Civil Judgments

Civil judgments are actions (other than criminal convictions) that are rendered in a federal or state court. A civil judgment against a health care practitioner, provider, or supplier is reportable when it is related to the delivery of a health care item or service, regardless of whether the judgment is on appeal.

• Federal and state attorneys and health plans must report these civil judgments.
• Federal or state attorneys in a multi-party suit must report the entire action, including all amounts awarded to all claimants, both public and private.
• If federal or state attorneys are not a party, but there is a health plan or multiple health plan claimants, the health plan with the largest award must report the total action for all parties.

Note: Consent judgments that have been agreed upon and entered to provide security for civil settlements in which there was no finding or admission of liability are not reportable. See the Reporting Health Care-Related Civil Judgments section of the NPDB Guidebook for more information.

How to Submit a Health Care-Related Civil Judgment Report

1. Sign in to the NPDB and select Report on the Select an Option page.
2. On the Identify the Subject page, select whether the subject is an Organization or an Individual, then enter the subject's name.
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   Identify the Subject

   
3. Select that you are reporting a Civil Judgment on the following page.
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   Select the Action

   
4. Complete the Subject Information section. Be sure to fill out as much information as possible to help querying organizations find your report.
   1. If the subject is a person, enter their personal information, such as name and birth date. If the subject is an organization, enter the organization name, type, and description.
   2. Enter the subject's home and work address and organization name, or enter the organization's address and principal owners.
   3. If the subject is a person, enter the type of license against which the action was taken.
   4. Enter the subject or organization's known identification numbers, which include a Social Security Number, IRS Taxpayer ID Number/Employer ID Number, National Provider Number, or Drug Enforcement Administration Number.
   5. Enter the health care entity or entities with which the subject is affiliated. If the subject is an organization, also enter the organization's state licensure information.
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   Subject Information

   
5. Complete the Action Information section.
   1. Enter the adverse action information such as the jurisdiction, the venue (court name) and location of the venue, the docket or court file number, the prosecuting agency or civil plaintiff and corresponding case number. Also, enter the name of the investigating agency, the corresponding case number, and the statute information.
   2. Enter the act or omission and describe the subject's acts or omissions and reason the action was taken.
   3. Enter the sentence/judgment information, such as the date of the sentence or judgment, whether the action is on appeal and the date of said appeal, the amount of restitution and other amount ordered, the sentence or judgment type and length, and any other court orders.
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   Action Information

   
6. Review the information you provided to ensure it is correct, then complete the Certification Section.
7. At the end of the Certification Section, click "Save and finish later" or "Submit to the NPDB".
8. Scan or print a copy of the report on the Report Submission Complete page for your records.
9. As noted in the NPDB Guidebook, entities are not excused from reporting simply because they missed a reporting deadline. Reports must still be submitted as soon as possible after a deadline is missed.

For more comprehensive instructions and requirements for health care-related civil judgment reports, see the NPDB regulations and the NPDB Guidebook.

Looking for information on how to submit other types of reports? Check out our Introduction to Reporting, Reporting Clinical Privileges Actions, Reporting State Licensure Actions, and Reporting Medical Malpractice Payments articles. Keep an eye on NPDB Insights for upcoming articles on how to report health care-related criminal convictions and other adjudicated actions or decisions.

Dear NPDB

What Does the NPDB Consider a Health Plan?

A health plan is a program that provides health benefits, whether directly, through insurance, through reimbursement, or otherwise.

Health plans include, but are not limited to, the following:

• A policy of health insurance
• A contract of a service benefit organization
• A membership agreement with a health maintenance organization or another prepaid health plan
• A plan, program, agreement, or other mechanism established, maintained or made available by a self-insured employer or group of self-insured employers: a health care practitioner, provider, or supplier group; a third-party administrator; an integrated health care delivery system; an employee welfare association; or a public service group or organization or professional association
• An insurance company, service, or organization that is licensed to engage in the business of selling health care insurance in a state and is subject to the state law that regulates health insurance
• An organization that provides benefit plans with coverage limited to outpatient prescription drugs

See the NPDB Guidebook for more examples of health plans.

What About Health Plans That Also Function as Other Health Care Entities?

Some health plans (such as health networks, health insurers, health maintenance organizations, and managed care organizations) may function as other health care entities (as defined in the NPDB Guidebook), in addition to being health plans.

Based on the actions your health plan takes, you may have two separate reporting requirements. Health plans that are required to report other adjudicated actions or decisions may be required to submit separate reports for clinical privileges/panel membership if those actions meet NPDB reporting requirements.

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," the health plan must submit each action as a separate report. The network participation action must be submitted as a clinical privileges action and the contract termination must be submitted as an other adjudicated action or decision.

Knowing how your organization fits within the NPDB's regulatory requirements is important for fulfilling your reporting, querying, and attestation obligations. If you are unsure how or if your organization should be registered with the NPDB, visit our Health Care Organization Help Center or the NPDB Guidebook.