Reporting Other Adjudicated Actions or Decisions

Federal agencies, state law enforcement agencies, state Medicaid fraud control units, state agencies administering or supervising the administration of a state health care program, and health plans must report other adjudicated actions or decisions against health care practitioners, providers, and suppliers (regardless of whether the action or decision is subject to a pending appeal). Among the specified state agencies, only the state agency that takes an adjudicated action or decision against a health care practitioner, provider, or supplier is responsible for reporting that action to the NPDB.

Table E-25 outlines reporting obligations for other adjudicated actions or decisions.

The term "other adjudicated actions or decisions" means:

• Formal or official final actions taken against a health care practitioner, provider, or supplier by a federal agency, state law enforcement agency, state Medicaid fraud control unit, state agency administering or supervising the administration of a state health care program, or health plan;
• That include the availability of a due process mechanism; and
• That are based on acts or omissions that affect or could affect the payment, provision, or delivery of a health care item or service.

A hallmark of any valid adjudicated action or decision is the availability of a due process mechanism. The fact that the subject elects not to use the due process mechanism provided by the authority bringing the action is immaterial, as long as such a process is available to the subject before the adjudicated action or decision is made final. In general, if an adjudicated action or decision follows an agency's established administrative procedures (which ensure that due process is available to the subject of the final adverse action), it would qualify as a reportable action under this definition. For health plans that are not government entities, an action taken following adequate notice and the opportunity for a hearing that meets the standards of due process set out in Title IV also would qualify as a reportable action.

The definition of "other adjudicated action or decision" specifically excludes the following:

• Clinical privileges actions and similar paneling decisions made by health plans
• Overpayment determinations and denial of claims determinations
• Business or administrative decisions taken by health plans that result in contract terminations unrelated to health care fraud, abuse, or quality of care (e.g., a practitioner's contract is terminated because the practitioner no longer practices at a facility in the health plan's network; a health plan terminates all provider contracts in a certain geographic area because it ceases business operations in that area)

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.

Actions with respect to medical malpractice claims should not be reported in this category.

Federal agencies, state law enforcement agencies, state Medicaid fraud control units, state agencies administering or supervising the administration of a state health care program, and health plans also must report any revisions to a previously reported other adjudicated action or decision, including whether the action is on appeal. For more information, go to Types of Reports in this chapter.

Table E-26 provides guidance on when other adjudicated actions or decisions must be reported to the NPDB. Table E-27 describes which reporting format should be used for reporting other adjudicated actions or decisions to the NPDB.

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.

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 monetary penalty for each adverse action not reported. The penalty will be imposed and collected in the same manner as other civil money penalties 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.