Reporting Federal Licensure and Certification Actions

Federal licensing and certification agencies must report final adverse licensure and certification actions taken against health care practitioners, providers, or suppliers, regardless of whether the final adverse action is the subject of a pending appeal. Such final adverse actions include:

• Formal or official actions such as revocation or suspension of a license, certification agreement, or contract for participation in government health care programs; reprimand; censure; or probation
• Any dismissal or closure of the proceedings because the health care practitioner, provider, or supplier surrendered a license, certification agreement, or contract for participation in government health care programs, or left the state or jurisdiction
• Any other loss of the license, certification agreement, or contract for participation in government health care programs, or the right to apply for, or renew, a license, certification agreement, or contract of the health care practitioner, provider, or supplier, whether by operation of law, voluntary surrender, nonrenewal (excluding nonrenewals due to nonpayment of fees, retirement, or change to inactive status), or otherwise
• Any other negative action or finding by a federal licensing or certification agency that is publicly available information, including but not limited to limitations on the scope of practice, liquidations, injunctions, and forfeitures. This definition also includes final adverse actions rendered by a federal licensing or certification agency - such as exclusions, revocations, or suspension of license or certification - that occur in conjunction with settlements in which no finding of liability has been made (although such a settlement itself is not reportable). This definition excludes administrative fines or citations, corrective action plans, and other personnel actions, unless:
  • the underlying action is connected to the delivery of health care services, or
  • the action is taken in conjunction with other adverse licensure or certification actions, such as revocation, suspension, censure, reprimand, probation, or surrender

When a license, agreement, or contract is suspended, the length of the suspension must be reported. In addition, federal licensing and certification agencies must report any revisions to a previously reported licensing or certification action, such as a reinstatement of a suspended license, and whether an action is on appeal. For more information, go to Types of Reports in this chapter.

Settlements in which no findings or admissions of liability have been made are statutorily excluded from being reported. However, actions that occur in conjunction with settlements in which no findings of liability have been made and that otherwise meet NPDB reporting requirements must be reported.

Table E-12 outlines reporting obligations for federal licensure and certification actions.

Certification

In the NPDB regulations, the term "certification" has two distinct meanings. First, the term is related to licensure, because licensure includes certification and other forms of authorization to provide health care services. This term can apply to agencies that "license," "certify," or "register" certain types of health care practitioners, entities, providers, or suppliers.

Second, the term "certification" also is used to refer to certification of a health care practitioner, provider, or supplier to participate in a government health care program. In this context, certification includes certification agreements and contracts for participation in a government health care program.

Administrative Fines and Formal Money Penalties

Federal licensing and certification agencies must report to the NPDB all money penalties and administrative fines that are formal or official actions (e.g., formal disciplinary actions) against health care practitioners, providers, or suppliers.

However, fines that are considered administrative or technical in nature must be reported to the NPDB only if they meet the NPDB definition of negative actions or findings. First, these types of administrative fines must be publicly available information. In addition, administrative fines reported as negative actions or findings must be either:

• Connected to the delivery of health care services, or
• Taken in conjunction with other adverse licensure or certification actions, such as revocation, suspension, censure, reprimand, probation, or surrender.

Generally, each reporting entity determines whether its action is connected to the delivery of health care services.

An action must be reported to the NPDB based on whether it satisfies NPDB reporting requirements and not based on the name affixed to the action.

Publicly Available Information

Publicly available information means that information is accessible to the interested public. This can occur in a variety of ways, including, but not limited to, phone, writing, electronic media (e.g., website or portal), or other media available for general distribution to any member of the public.

Stayed Actions

A licensure or certification action imposed with a stay should not be reported to the NPDB as long as the entire action is stayed. When only part of the action is stayed, the part of the action that is not stayed must be reported. In addition, if a stayed action is accompanied by another reportable action, the reportable action that accompanied the stayed action must be reported.

Denials of Initial and Renewal Applications

Federal licensing and certification agencies must report to the NPDB denials of initial and renewal applications for licensure or certification for health care practitioners, providers, or suppliers if the denials are formal or official final adverse actions. For example, if a federal licensing agency takes a final action to deny a practitioner's initial licensure application because the practitioner misrepresented information on the application, that action is reportable.

Federal licensing or certification agencies should not report cases in which the agency denies the licensure or certification only because a health care practitioner, provider, or supplier does not meet the threshold criteria for licensure or certification.

Withdrawals of Initial and Renewal Application While Under Investigation, and Failure to Renew While Under Investigation

Investigations should not be reported to the NPDB. However, withdrawal of a renewal application for licensure or certification, while the federal licensure or certification authority is investigating the applicant, is reportable. In addition, an applicant's withdrawal, for any reason, of an initial application for licensure or certification is not reportable, even if the applicant is under investigation.

The NPDB interprets the word "investigation" expansively, although the investigation must be focused on a specific individual or entity. For example, if a federal licensing board routinely runs a criminal background check on all applicants for license renewal, that is not considered an investigation. If, as a result of the routine check, the board decides to further examine a specific applicant's record, that examination is considered an investigation. The NPDB retains the ultimate authority to determine whether an investigation exists.

The NPDB considers an investigation to run from the start of an inquiry until a final decision is reached. In other words, an investigation is not limited to a federal licensure or certification authority's gathering of facts or by the manner in which the federal licensing or certification authority defines the term "investigation." An investigation begins as soon as the federal licensure or certification authority begins a nonroutine inquiry and does not end until the authority's decision-making body takes a final action or makes a decision not to further pursue the matter.

A licensure or certification authority that submits a report based on a withdrawal of a renewal application while the applicant is under investigation should have evidence of an ongoing investigation at the time of withdrawal. Examples of acceptable evidence may include minutes or excerpts from committee meetings, orders from licensing or certification officials directing an investigation, or notices to renewal applicants of an investigation. (The licensure or certification authority must be able to show that the practitioner was notified of the investigation, although actual knowledge of the investigation on the part of the practitioner is not required.)

Guidelines for Investigations

• For NPDB reporting purposes, the term "investigation" is not controlled by how that term may be defined by a licensing or certification authority's policies and procedures.
• A routine review of a particular practitioner is not an investigation.
• The investigation must be focused on the practitioner in question.
• To be considered an investigation for purposes of determining whether an activity is reportable, the activity generally should be the precursor to a licensure or certification action.
• An investigation is considered ongoing until the licensing or certification authority's decision-making authority takes a final action or formally closes the investigation.

Voluntary Surrenders

Federal licensing and certification agencies are required to report voluntary surrenders of a license, certification agreement, or contract for participation in a government health care program by a health care practitioner, provider, or supplier. NPDB regulations define a voluntary surrender of a license or certification as "a surrender made after a notification of investigation or a formal official request by a federal or state licensing or certification authority for a health care practitioner, health care entity, provider, or supplier to surrender the license or certification (including certification agreements or contracts for participation in federal or state health care programs). The definition also includes those instances where a health care practitioner, health care entity, provider, or supplier voluntarily surrenders a license or certification (including program participation agreements or contracts) in exchange for a decision by the licensing or certification authority to cease an investigation or similar proceeding, or in return for not conducting an investigation or proceeding, or in lieu of a disciplinary action."

The voluntary relinquishment of a license for personal reasons such as retirement or illness is not reportable to the NPDB if no other action or investigation is in progress. Only the surrender of the license while under investigation, or in return for not conducting an investigation, is reportable.

Confidentiality Laws Related To Drug and Alcohol Treatment

If a licensure or certification action is taken and the practitioner enters a treatment or rehabilitation program as a result, the adverse action must be reported. This is true even if the treatment is a condition of probation. However, the fact that the health care practitioner entered a drug or alcohol treatment facility should not be reported.

If a health care practitioner (or other reportable individual) voluntarily enters a treatment or rehabilitation program at the direction or suggestion of a licensing or certification agency, a report should not be submitted to the NPDB.

Sanctions for Failing to Report

If HHS determines that a federal licensing or certification agency 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

Table E-13 provides guidance on when federal licensure or certification actions must be reported to the NPDB. Table E-14 describes which reporting format should be used for reports on federal licensure and certification actions.