Chapter D: Queries

Overview

The NPDB is an information clearinghouse created by Congress with the primary goals of improving health care quality, protecting the public, and reducing health care fraud and abuse in the United States. The NPDB collects information on medical malpractice payments and certain adverse actions and discloses that information to eligible entities to facilitate comprehensive reviews of the credentials of health care practitioners, entities, providers, and suppliers. These payments and actions are required to be reported to the NPDB under Title IV of Public Law 99-660, the Health Care Quality Improvement Act of 1986 (Title IV); Section 1921 of the Social Security Act (Section 1921); Section 1128E of the Social Security Act (Section 1128E); and their implementing regulations found at 45 CFR Part 60.

NPDB information is intended to be used in combination with information from other sources when entities are making decisions regarding licensure, employment, contracting, membership or clinical privileges, or when conducting investigations. The information available to an entity that submits a query to the NPDB is determined by the legislation authorizing the entity's eligibility to query. Fees are charged for all queries submitted to the NPDB.

The limited access provisions of the laws governing the NPDB do not permit disclosure to the general public of NPDB information that identifies the subjects of reports. However, data for statistical analysis purposes are available on the NPDB's website and can be downloaded. The Data Analysis Tool allows researchers to define and generate de-identified data sets for NPDB reports submitted on practitioners from 1990 through the end of the most recent available calendar year. The Public Use Data File supplies de-identified information to researchers, journalists, and others to use to report on trends in patient safety and state reporting. More specific data requests may be honored upon request. However, under federal law, NPDB information cannot be used alone or in combination with other data to identify any individual or organization.

Table D-1 summarizes the NPDB information that is available to each type of authorized querier under each of the three statutes described above. Refer to Chapter E: Reports for more information regarding the types of actions that are reported to the NPDB.

The sections following Table D-1 contain detailed information about what entities and individuals must or may query the NPDB, including information about the type of information available to the specific entities or individuals and how the specific entities and individuals are permitted to use the information they obtain from the NPDB.

When an entity queries the NPDB, the NPDB determines how the entity is registered with the NPDB before releasing information, and it releases only lawfully permitted information based on the entity's registration. Consequently, queriers do not have to know what categories of information are available to them, although the sections below explain the type of information available. However, because the NPDB releases information based upon an entity's registration, entities that query the NPDB must make sure they are properly registered. Most authorized entities are only permitted to query the NPDB at specific times, such as when a practitioner is applying for privileges or a license, or for a specific reason. Entities must be certain that they are querying only for authorized purposes.

Hospitals

Hospitals are the only health care entities mandated by federal law to query the NPDB. Each hospital must request information from the NPDB as follows:

• When a physician, dentist, or other health care practitioner applies for medical staff appointment (courtesy or otherwise) or for clinical privileges at the hospital, including temporary privileges.
• Every 2 years (biennially) on all physicians, dentists, and other health care practitioners who are on its medical staff (courtesy or otherwise) or who hold clinical privileges at the hospital.

The biennial query may be done in accordance with regular medical staff reappointment and clinical privilege re-delineation. Additionally, hospitals are required to query the NPDB each time a practitioner wishes to add to or expand existing privileges. Hospitals also must query when a practitioner applies for temporary privileges. Hospitals are not required to query more than once every 2 years on a practitioner who is continuously on staff unless the practitioner wishes to add to or expand existing privileges or when a practitioner submits an application for temporary privileges. For example, if a practitioner applies for temporary clinical privileges four times in 1 year, the hospital must query the NPDB on each of those four occasions.

Hospitals are required to query on courtesy staff who are considered part of the medical staff, even if afforded only nonclinical professional courtesies such as use of the medical library and continuing education facilities. If a hospital extends nonclinical practice courtesies without appointing practitioners to a medical staff category, querying is not required on those practitioners.

Locum Tenens

A hospital is required to query the NPDB each time a locum tenens practitioner makes an application for temporary privileges. To reduce the query burden, hospitals that frequently use particular locum tenens practitioners may choose to appoint such practitioners to their consultant staff or other appropriate staff category in accordance with their bylaws and then query on the practitioners when their 2-year appointment is due for renewal.

Residents and Interns

Whether a hospital is required to query on an intern or resident depends upon whether the intern or resident is a member of the medical staff. Health care entities are not required to query the NPDB on medical and dental residents, interns, or staff fellows (collectively referred to as house staff), even though they are often licensed, when they are trainees in structured programs of supervised graduate medical education and not members of the medical staff.

There is no difference between the house staff of the clinical facility belonging to the formal medical education program and the house staff rotating to a clinical facility providing a clinical training site for the formal medical educational program. Hospitals are not required to query the NPDB on house staff providing services as part of their formal medical education.

However, hospitals are required to query on house staff when such individuals are appointed to the medical staff or granted clinical privileges to practice outside the parameters of the formal medical education program (e.g., moonlighting in the intensive care unit or emergency department of that hospital).

Physicians, Dentists, and Other Health Care Practitioners

In addition to the mandatory requirements for querying, hospitals may request information from the NPDB at any time they deem necessary with respect to professional review activity. Furthermore, hospitals and their human resources and recruiting departments may query on all types of health care practitioners (e.g., nurses, nurse aides, physical therapists) with respect to making determinations regarding employment or affiliation relationships.

Results of Hospital Queries

Hospitals must query in the following situations:

• When a physician, dentist, or other health care practitioner applies for medical staff appointment (courtesy or otherwise) or for clinical privileges, including temporary privileges
• Every 2 years (biennially) on all physicians, dentists, and other health care practitioners who are on the medical staff (courtesy or otherwise) or who hold clinical privileges
• When a health care practitioner wishes to add to or expand existing privileges and when a practitioner submits an application for temporary privileges
• Each time a locum tenens health care practitioner makes an application for temporary privileges
• On residents and interns when such individuals are appointed to the medical staff or granted clinical privileges to practice outside the parameters of a formal medical education program

Generally, hospitals may query when the hospital is entering into an employment or affiliation relationship with the health care provider, or when the hospital is engaging in professional review activity.

Hospitals receive the following types of information in response to their queries:

• Medical malpractice payment information
• Licensure actions by boards of medical examiners
• Licensing and certification actions taken by states
• Federal licensing and certification actions
• Adverse actions taken by health care entities against clinical privileges, including professional review actions taken by professional societies
• Negative actions or findings by peer review organizations or private accreditation entities
• Health care-related criminal convictions
• Health care-related civil judgments
• Exclusions from participating in federal or state health care programs
• Other health care-related adjudicated actions or decisions

Failure to Query

If a hospital does not query on a practitioner when required, the hospital is presumed to be aware of the information reported to the NPDB concerning the practitioner. A hospital's failure to query on a practitioner may give a plaintiff's attorney or plaintiff representing himself or herself access to NPDB information on that practitioner for use in litigation against the hospital.

Other Health Care Entities

Other health care entities generally may query the NPDB:

• When they have or may be entering into employment or affiliation relationships with health care practitioners
• When health care practitioners apply for clinical privileges or medical staff appointments
• When they are engaging in professional review activity

Other health care entities receive the following types of information in response to their queries:

• Medical malpractice payment information
• Licensure actions by boards of medical examiners
• Licensure and certification actions taken by states
• Adverse actions taken by health care entities against clinical privileges, including professional review actions taken by professional societies
• Negative actions or findings by peer review organizations or private accreditation entities
• Health care-related criminal convictions when reported by federal agencies or health plans
• Health care-related civil judgments when reported by federal agencies or health plans
• Exclusions from participating in federal or state health care programs when reported by federal agencies or health plans
• Other health care-related adjudicated actions or decisions when reported by federal agencies or health plans

Agencies Administering Government Health Care Programs, Including Private Entities Administering Such Programs Under Contract

Federal and state agencies administering government health care programs, including private entities administering such programs under contract, may query:

• When they are determining the fitness of individuals to provide health care services
• When they are protecting the health and safety of individuals receiving health care through programs they administer
• When they are protecting the fiscal integrity of programs they administer

Agencies administering government health care programs, including private entities administering such programs under contract, receive the following types of information in response to their queries:

• Licensure and certification actions taken by states
• Federal licensing and certification actions
• Negative actions or findings by peer review organizations or private accreditation entities
• Health care-related criminal convictions
• Health care-related civil judgments
• Exclusions from participating in federal or state health care programs
• Other health care-related adjudicated actions or decisions

Federal Law Enforcement Officials and Agencies

Federal law enforcement officials and agencies may query the NPDB:

• When they are determining the fitness of individuals to provide health care services
• When they are protecting the health and safety of individuals receiving health care through programs they administer
• When they are protecting the fiscal integrity of programs they administer

Federal law enforcement officials and agencies receive the following types of information in response to their queries:

• Licensure and certification actions taken by states
• Federal licensing and certification actions
• Negative actions or findings by peer review organizations or private accreditation entities
• Federal or state health care-related criminal convictions
• Health care-related civil judgments
• Exclusions from participating in federal or state health care programs
• Other health care-related adjudicated actions or decisions

Federal Licensing and Certification Agencies

Federal licensing and certification agencies responsible for the licensing or certification of health care practitioners, providers, or suppliers may query the NPDB:

• When they are determining the fitness of individuals to provide health care services
• When they are protecting the health and safety of individuals receiving health care through programs that they administer
• When they are protecting the fiscal integrity of the programs they administer

Federal licensing and certification agencies responsible for the licensing or certification of health care practitioners, providers, or suppliers receive the following types of information in response to their queries:

• Licensure and certification actions taken by states
• Federal licensing and certification actions
• Negative actions or findings by peer review organizations or private accreditation entities
• Federal or state health care-related criminal convictions
• Health care-related civil judgments
• Exclusions from participating in federal or state health care programs
• Other health care-related adjudicated actions or decisions

Health Plans

Health plans may query the NPDB:

• When they are determining the fitness of individuals to provide health care services
• When they are protecting the health and safety of individuals receiving health care through programs they administer
• When they are protecting the fiscal integrity of programs they administer

Health plans receive the following types of information in response to their queries:

• Licensure and certification actions taken by states
• Federal licensing and certification actions
• Negative actions or findings by peer review organizations or private accreditation entities
• Federal or state health care-related criminal convictions
• Health care-related civil judgments
• Exclusions from participating in federal or state health care programs
• Other health care-related adjudicated actions or decisions

Professional Societies

Professional societies generally may query the NPDB:

• When entering into an employment or affiliation (membership) relationship with a health care practitioner
• When engaging in a professional review activity

Professional societies receive the following types of information in response to their queries:

• Medical malpractice payment information
• Licensure actions by boards of medical examiners
• Licensure and certification actions taken by states
• Adverse actions taken by health care entities against clinical privileges, including professional review actions taken by professional societies
• Negative actions or findings by peer review organizations or private accreditation entities
• Health care-related criminal convictions when reported by federal agencies or health plans
• Health care-related civil judgments when reported by federal agencies or health plans
• Exclusions from participating in federal or state health care programs when reported by federal agencies or health plans
• Other health care-related adjudicated actions or decisions when reported by federal agencies or health plans

Quality Improvement Organizations

Quality improvement organizations may query the NPDB:

• When they are determining the fitness of individuals to provide health care services
• When they are protecting the health and safety of individuals receiving health care through programs they administer
• When they are protecting the fiscal integrity of programs they administer

Quality improvement organizations receive the following types of information in response to their queries:

• Licensure and certification actions taken by states
• Negative actions or findings by peer review organizations or private accreditation entities
• Health care-related criminal convictions when reported by federal agencies or health plans
• Health care-related civil judgments when reported by federal agencies or health plans
• Exclusions from participating in federal or state health care programs when reported by federal agencies or health plans
• Other health care-related adjudicated actions or decisions when reported by federal agencies or health plans

State Agencies Administering or Supervising the Administration of a State Health Care Program

State agencies administering or supervising the administration of a state health care program may query the NPDB:

• When they are determining the fitness of individuals to provide health care services
• When they are protecting the health and safety of individuals receiving health care through programs they administer
• When they are protecting the fiscal integrity of programs they administer

State agencies administering or supervising the administration of a state health care program receive the following types of information in response to their queries:

• Licensure and certification actions taken by states
• Federal licensing and certification actions
• Negative actions or findings by peer review organizations or private accreditation entities
• Federal or state health care-related criminal convictions
• Health care-related civil judgments
• Exclusions from participating in federal or state health care programs
• Other health care-related adjudicated actions or decisions

State Law Enforcement Agencies and State Medicaid Fraud Control Units

State law enforcement agencies and state Medicaid fraud control units may query the NPDB:

• When they are determining the fitness of individuals to provide health care services
• When they are protecting the health and safety of individuals receiving health care through programs they administer
• When they are protecting the fiscal integrity of programs they administer

State law enforcement agencies and state Medicaid fraud control units receive the following types of information in response to their queries:

• Licensure and certification actions taken by states
• Federal licensing and certification actions
• Negative actions or findings by peer review organizations or private accreditation entities
• Federal or state health care-related criminal convictions
• Health care-related civil judgments
• Exclusions from participating in federal or state health care programs
• Other health care-related adjudicated actions or decisions

State Licensing and Certification Agencies

State licensing and certification agencies may query the NPDB:

• When they are determining the fitness of individuals to provide health care services
• When they are protecting the health and safety of individuals receiving health care through programs that they administer
• When they are protecting the fiscal integrity of the programs they administer

State licensing and certification agencies receive the following types of information in response to their queries:

• Licensure and certification actions taken by states
• Federal licensing and certification actions
• Negative actions or findings by peer review organizations or private accreditation entities
• Federal or state health care-related criminal convictions
• Health care-related civil judgments
• Exclusions from participating in federal or state health care programs
• Other health care-related adjudicated actions or decisions

State Medical Boards of Examiners or Other State Authorities that License Health Care Practitioners

State medical boards of examiners or other state authorities that license health care practitioners may query the NPDB at any time. These authorities receive the following types of information in response to their queries:

• Medical malpractice payment information
• Licensure actions by boards of medical examiners
• Adverse actions taken by health care entities against clinical privileges, including professional review actions taken by professional societies

Note that entities that qualify as state medical boards of examiners or other state authorities that license health care practitioners also qualify as state licensing and certification agencies and therefore are eligible to receive information listed under that section.

Health Care Practitioners, Entities, Providers, and Suppliers

Health care practitioners, entities, providers, and suppliers may request information concerning themselves from the NPDB (Self-Query) at any time.

Attorney Access

A plaintiff's attorney or a plaintiff representing himself or herself is permitted to obtain certain information from the NPDB under the following limited conditions:

• A medical malpractice action or claim must have been filed by the plaintiff against a hospital in a state or federal court or other adjudicative body;
• The practitioner on whom the information is requested must be named in the action or claim; and
• Evidence must be submitted to the Department of Health and Human Services demonstrating that the hospital failed to submit a mandatory query to the NPDB regarding the practitioner named by the plaintiff in the action.

Evidence that the hospital failed to query the NPDB must be obtained by the plaintiff from the hospital through discovery in the litigation process. This evidence is not available to the plaintiff through the NPDB.

The plaintiff's attorney must submit all of the following to the NPDB:

• A letter requesting authorization to obtain information
• Supporting evidence that the hospital did not make a mandatory query of the NPDB regarding the practitioner named by the plaintiff in the action or claim
• Identifying information about the practitioner on whom the attorney wishes to query

The letter should be sent to one of the following addresses:

Standard Mail	Overnight Mail
National Practitioner Data Bank P.O. Box 10832 Chantilly, VA 20153-0832	National Practitioner Data Bank 4094 Majestic Lane PMB-332 Fairfax, VA 22033

Examples of evidence may include a deposition, a response to an interrogatory, an admission, or other evidence of the failure of a hospital to request information. The plaintiff's attorney must submit a separate request for information disclosure for each practitioner named in the action or claim. If the NPDB concludes that attorney access is appropriate in a specific case, it will give the hospital an opportunity to respond to the request before releasing the requested information.

The approval of a request by a plaintiff's attorney is limited to a one-time-only disclosure; the approval of such a request does not allow a plaintiff's attorney to obtain NPDB information on a continuing basis. Subsequent disclosures of NPDB information require the plaintiff's attorney to initiate a new request. A fee is assessed when the NPDB discloses such information.

An approved query request entitles the plaintiff's attorney to receive only that information available in the NPDB at the time the hospital was required to query but did not. It also includes information on any reports that subsequently were voided. Information that will be made available to the plaintiff's attorney is limited to reports submitted to the NPDB under the authority of Title IV, including medical malpractice payments, state licensure actions taken by a state medical or dental board, clinical privileges actions, professional society membership actions, Drug Enforcement Administration controlled-substance registration actions, and exclusions from Medicare, Medicaid, and other federal health care programs.

There are limitations on the use of information obtained by the plaintiff in a judicial proceeding. Specifically, the information obtained from the NPDB on the practitioner can be used only with respect to a legal action or claim against the hospital, not against the practitioner. Any further disclosure or use violates the NPDB confidentiality provisions and subjects the plaintiff's attorney and/or plaintiff to a civil money penalty imposed pursuant to Section 1128A of the Social Security Act, 42 USC § 1320a-7a. Regulations governing civil money penalties under Section 1128A are set forth at 42 CFR Part 1003.