Examples of Dispute Resolution

The following examples assume that the subject of the report entered the report into Dispute Status, made a request to elevate the report to Dispute Resolution, and met the other prerequisites for having the report elevated.

The Report is Accurate as Submitted

1. A Medical Malpractice Payment Report (MMPR) was submitted to the NPDB naming a licensed medical resident as the subject of the report. The resident claimed that the report was improperly submitted because she was still in training at the time of the incident.

   Outcome: The report was submitted in accordance with NPDB reporting requirements based on the definition of health care practitioner: "an individual who is licensed or otherwise authorized by the state to provide health care services (or any individual who, without authority holds himself or herself out to be so licensed or authorized)." Whether the health care practitioner is in training is irrelevant when reporting medical malpractice payments. The report was found to be accurate as submitted.

2. A provider was named as the subject of a report on a health care-related criminal conviction. The provider argued that he was not convicted of a crime because he had pleaded nolo contendere to an allegation of submitting false claims to a health plan.

   Response: The report was submitted in accordance with NPDB reporting requirements based on the definition of criminal conviction, which includes a nolo contendere plea. The report was found to be accurate as submitted.

3. A state licensure action report was submitted to the NPDB naming an ambulance service as the subject. The ambulance service was reprimanded for "failing to assure that critical patient care equipment has spare batteries or an alternative power source." The ambulance service claimed that it had run out of batteries only once but the narrative implied that this was an ongoing problem.

   Response: The narrative was reviewed against the materials provided by the state licensing board and the report was found to be accurate as submitted.

4. A hospital reported a clinical privileges action to the NPDB indicating that a surgeon resigned while under investigation. The surgeon objected, saying she did not know she was under investigation. She insisted that an investigation was never mentioned to her and there is no mention of investigations in the hospital bylaws. For these reasons, she said, the report should be removed from the NPDB.

   Response: A hospital must submit a report to the NPDB when a physician or dentist resigns his or her clinical privileges while under investigation, regardless of whether the health care practitioner is aware of the investigation. The hospital provided documentation of an ongoing investigation at the time the surgeon resigned her clinical privileges. Therefore, the report was found to be accurate as submitted.

The Report is Inaccurate as Submitted

1. A report of a state licensure action taken against a chiropractor was submitted to the NPDB. The chiropractor claimed the narrative was misleading because it cited "patient harm" but the state licensing board's finding was "inappropriate communication." The chiropractor requested that the description be changed.

   Outcome: The narrative was reviewed against the findings submitted by the state licensing board and was found not to accurately reflect the board's findings of fact and conclusion of law. The reporting entity was directed to change the narrative.

2. A report of a summary suspension of clinical privileges was submitted to the NPDB. The subject of the report, a physician, argued that the report was illegally submitted because the suspension was less than 30 days. Specifically, the hospital reported the suspension of the physician's clinical privileges on the 10th day of an indefinite suspension. As part of the suspension, the physician was required to undergo a psychiatric evaluation. The physician completed the required action on the 20th day of the suspension. The psychiatric evaluation was unremarkable, and clinical privileges were immediately restored. The hospital did not void the report from the NPDB.

   Outcome: The reporting entity was directed to void the report because only clinical privileges actions in effect or imposed for more than 30 days may be reported to the NPDB, and the summary suspension the reporting entity took lasted only 20 days. The hospital erred in not voiding the report after the physician's privileges were restored on the 20th day, but it may have properly submitted the report initially. When a summary suspension of clinical privileges is indefinite in length but is expected to last more than 30 days, and is otherwise reportable, it may be reported to the NPDB immediately. If the summary suspension ultimately does not last more than 30 days, the report must be voided.

3. A hospital submitted a report to the NPDB regarding a physician's summary suspension of clinical privileges based on professional competence. The suspension lasted 28 days. The hospital took no subsequent action. The physician resigned a year later while still under investigation by the hospital for the same professional competence issue. The hospital submitted a second report related to the physician's resignation while under investigation.

   After the second report was submitted, the physician disputed both reports. The physician argued that the first report was not submitted in accordance with the NPDB reporting requirements because the length of the suspension was less than 30 days and that the second report also was submitted illegally because it was based on the same issue that had previously been illegally reported to the NPDB.

   Outcome: The reporting entity was directed to void the first report because the summary suspension was neither in effect nor imposed for more than 30 days, as required for clinical privileges actions submitted to the NPDB. The second report was found to be accurate as submitted because the physician had resigned while under investigation for issues related to professional competence.

4. A hospital reported a clinical privileges action stating that a surgeon had exhibited improper and unprofessional conduct. The physician argued that the report did not adequately describe his conduct, which he described as essential to saving the life of a patient.

   Outcome: The narrative was found to be factually insufficient and the hospital was asked to correct it. When the hospital failed to correct the narrative, the NPDB corrected the narrative consistent with the record compiled during Dispute Resolution. The corrected narrative indicated that the surgeon had to be restrained by the police after he became upset because he had to wait for an operating room. The surgeon had insisted that a trauma patient needed immediate attention. Two other surgeons, however, had determined that the patient's injuries were not life threatening. As a result, a nurse refused to let the surgeon operate.

5. A physician was completing his surgical residency and applied for board certification in surgery at the same time he applied for surgical privileges at a hospital. The hospital denied his application for surgical privileges when it received notice that that the physician was not awarded board certification, a threshold eligibility criteria for privileges at that hospital. The hospital reported the action to the NPDB, and the physician disputed the report.

   Outcome: The denial of surgical privileges solely because a physician does not meet the hospital's established threshold eligibility criteria should not be reported to the NPDB. Such denials are not a result of a professional review action relating to the practitioner's professional competence or conduct. The hospital was directed to void the report.

The Issues in Dispute are Outside the Scope of Dispute Resolution

1. A health care practitioner was the subject of a clinical privileges action report. He alleged that the health care entity, during professional review, denied him due process. He claimed the reviewers ignored the testimony of medical experts and other witnesses called to prove various points that he believed were important to his defense.

   Outcome: The issue raised by the subject of the report (i.e., whether due process was afforded the subject of the report) was found to be outside the scope of review because it did not concern the report's factual accuracy or whether the report was submitted in accordance with NPDB requirements.

2. A physician objected to an NPDB report because she did not think she was responsible for the incident that resulted in the restriction of her clinical privileges. She stated that she had only seen the patient once.

   Outcome: The issues raised in the dispute were found to be outside the scope of review because they addressed the basis for the clinical privileges action. The number of times a patient is seen by a health care practitioner or whether the health care practitioner accepts responsibility for the incident is irrelevant to reporting a clinical privileges action.

3. A health care practitioner argued against an MMPR, saying that he was not given the opportunity for a court hearing because his insurance company settled the claim without his knowledge.

   Outcome: The issues raised by the health care practitioner were found to be outside the scope of review. Whether the health care practitioner agreed to a settlement is irrelevant to the requirement for submitting an MMPR.

4. After a state licensing board submitted charges against him, a social worker entered into a consent order with the board, agreeing that his license would be suspended for 60 days, and the subsequent state licensure action was reported to the NPDB. The practitioner claimed that he never had a formal proceeding as defined in NPDB regulations: "a proceeding held before a state licensing or certification authority, peer review organization, or private accreditation entity that maintains defined rules, policies, or procedures for such a proceeding."

   Outcome: The issue regarding the lack of a formal proceeding was found to be outside the scope of review. The consent order the practitioner provided clearly stated that the social worker had an opportunity to consult legal counsel and, by signing the consent order, he agreed to forego the formal hearing process with the state licensing board. The board provided documentation showing that the activities surrounding the charge and consent order were activities held under a formal proceeding with defined rules, policies, and procedures to conduct such activities. By not availing himself of the formal hearing, the social worker cannot claim that a formal proceeding was not used.