By JESSE A. MARKOS, ESQ.
Wachler & Associates, P.C.
Hospitals have long been required to file a National Practitioner Data Bank (Data Bank) report on any health care provider’s voluntary surrender of clinical privileges if an investigation is underway or to avoid an investigation. In practice, the number of such cases that were reported was limited by the uncertainty and lack of sufficient guidance regarding which specific activities qualify as an “investigation” and when such an investigation officially commenced. However, the new adoption by the revised Data Bank Guidebook of an expanded description of what qualifies as a reportable investigation has resulted in increased reporting.
By way of background, the Data Bank is an alert system that collects and discloses certain adverse information about physicians and other health care providers. An adverse report to the Data Bank can significantly impact a health care provider’s reputation and career. State licensing authorities, hospitals and other health care entities, and professional societies search the Data Bank when investigating qualifications. A response that contains an adverse report can act as a permanent black mark and result in a denial of credentialing, loss or limitation of hospital privileges, loss or limitation of licensure, exclusion from participation in health plans, and increases in premiums or exclusion from professional liability insurance.
A Data Bank Guidebook is published to serves as a policy manual providing guidance to users on topics such as eligibility, querying and reporting requirements, and the dispute process. It was most recently revised in 2015, in part, to clear up any uncertainly regarding reporting requirements, including what constitutes an “investigation” and when one has commenced. According to the revised Data Bank Guidebook, the “[Data Bank] interprets the word ‘investigation’ expansively.” More specifically, it provides that “an investigation is not limited to a health care entity’s gathering of facts. An investigation begins as soon as the health care entity begins an inquiry and does not end until the health care entity’s decision-making authority takes a final action or makes a decision to not further pursue the matter.” However, the revised Guidebook does not provide a definition of the term “inquiry” or other sufficient guidance to clear up the ambiguity regarding the trigger event for an investigation. Nevertheless, this is a substantial departure from the previous interpretation as the purpose is to expand the description of what constitutes an “investigation” and a reportable surrender of privileges resulting in increased reporting.
Avoiding a Data Bank report is a central concern for many health care providers as a report can have serious professional and financial repercussions. As a result, hospitals and health care providers alike must become familiar with the expanded reporting requirements found in the revised Data Bank Guidebook to help understand when a report is required and how, if possible, one can appropriately be avoided. For additional information or assistance, contact Jesse A. Markos, Esq., of Wachler & Associates, P.C., at (248) 544-0888.