1. HIPDB: Reporting Responsibilities Federation of Chiropractic Licensing Boards 81 st Annual Congress May 4, 2007 LCDR Shari W. Campbell, DPM, MSHS U. S. Department of Health and Human Services Health Resources and Services Administration Bureau of Health Professions Practitioner Data Banks Branch

2. Overview HIPDB Background Report Data Compliance Activities System Improvements New Initiatives

3. HIPDB Background

4. HIPDB Purpose The intent is to protect the public, improve the quality of health care and deter fraud and abuse in the health care system by providing information about past adverse actions of practitioners, providers, or suppliers to authorized health care entities and agencies.

5. HIPDB Background Established through Section 1128E of the Social Security Act as amended by Section 221(a) of Public Law 104-191, the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Final regulations governing the HIPDB are codified at 45 CFR Part 61 All final adverse actions taken on or after August 21, 1996 must be reported

6. By Law, Who Must Report? State Government Entities Federal Government Entities Health Plans

7. Who May Query the HIPDB? Federal and State Government Agencies Health Plans Health Care Providers, Practitioners and Suppliers (self-query only) Researchers (non-identifiable statistical information)

8. Who is Reported? Health Care Providers Examples: Hospitals, Health Plans, PPOs, Medical Group Practices Health Care Practitioners Examples: Chiropractors, Podiatrists, Athletic Trainers, Registered Nurses, Certified Nurse Assistants Health Care Suppliers Examples: Durable Medical Equipment Suppliers, Pharmaceutical Suppliers and Manufacturers, Billing and Transportation Service Suppliers

9. What is Reportable? Federal and State licensing and certification agencies must report final adverse actions* that are taken against health care: Providers Practitioners Suppliers * Regardless of whether the final adverse action is the subject of a pending appeal

10. What is Reportable? Licensing and certification actions: Revocation, Suspension, Probation, Censure, Reprimand Any other loss of license or certification, or right to apply for, or renew a license whether by voluntary surrender, or non-renewal Any other negative action or finding that is publicly available information

11. What is Reportable? Criminal Convictions Federal and State Prosecutors must report criminal convictions* related to the delivery of a health care item or services Civil Judgments Federal and State attorneys and health plans must report civil judgments* related to the delivery of a health care item or services Exclusions Federal and State Government agencies must report health care providers, suppliers, or practitioners excluded* from participation in Federal or State health care programs *Regardless of whether the conviction is the subject of a pending appeal

12. What is Reportable? Other Adjudicated Actions Federal and State government agencies and Health Plans must report other adjudicated actions, * which are defined as: Formal or official final actions taken against health care practitioners, providers, or suppliers, which include the availability of a due process mechanism; and Are based on acts or omissions that affect or could affect the payment, provision, or delivery of a health care item or service *Regardless of whether the exclusion is the subject of a pending appeal

13. What is not Reportable? Medical Malpractice Payments Settlements in which no findings or admissions of liability have been made Temporary Actions; i.e. summary or emergency

14. HIPDB Data

15. What is in the HIPDB? Practitioner Reports Cumulative Data as of 12/31/06

16. What is in the HIPDB? Practitioner Reports Reports received in 2006

17. What is in the HIPDB? Organizations Cumulative Data as of 12/31/06

18. What is in the HIPDB? Organizations 2006 Data

19. HIPDB QUERIERS 8% 5% 2006 Data 64% 15.6% 5.7% 1.2%

20. Types of Reports on Chiropractors 200420052006Total # of Reports Licensure18430911351628 Malpractice235213208656 Exclusions1344869251 Health Plan11112896335 JOCR15101843 Clinical Privileges 651324 Note: Data represents the date that the action was submitted to the NPDB or HIPDB

21. Types of Reports on Chiropractors Note: Data represents the date that the action was submitted to the NPDB or HIPDB Number of Reports

22. Chiropractor Licensure Actions

23. HIPDB Compliance Activities

24. Convey the importance of timely reporting Holding Policy Forums and talking with leadership of composite State licensing boards Presenting to Associations/Federations of State licensing boards Presenting to State Association Medical Staff Services Regulations Mandates reporting within 30 days of the date of the final action. NPDB: Title IV of Public Law 99-660, the Health Care Quality Improvement Act of 1986, as amended and its implementing regulations (45 CFR Part 60) HIPDB: Section 1128E of the Social Security Act as added by Section 221(A) of the Health Insurance Portability and Accountability Act of 1996 and its implementing regulations (45 CFR Part 61)

25. Compliance Activities Monitor Timely Reporting Compare actions documented on State Licensing Board web sites to actions reported to the NPDB and/or HIPDB Identify and contact States that have not reported any actions to the NPDB and/or HIPDB Search other publicly available information for actions and payments that should have been reported Review reports that are filed and later voided Review a limited number of report narratives to determine if they are legally sufficient: Must include enough information so that future queriers knowing nothing about the events giving rise to the report will have an understanding of what the subject practitioner is alleged to have done, the nature of the action taken and the reasons for the report

26. Compliance Activities Compare NPDB payment reports to the NAIC summary payment reports (Supplement A to Schedule T) Review Medical Malpractice Payment Reports that mention High-Low agreements in the narrative to determine if the payment was made for the benefit of the: Practitioner (reportable) Insurer to avoid the risk of a higher payment when the finder of fact ultimately determines that the practitioner had no liability (not reportable) These reporters are asked to void the report Monitor the eligibility of Data Bank Registrants Monitor for violation of Confidentiality Rules

27. HIPDB System Improvements

28. June 18, 2007 System Release Ability to correct a Revision-to-Action Report (IQRS and ITP) Ability to update a Subject Address when entering a Dispute Statement or Secretarial Review Request Increase all Report Narratives and Subject Statements to 4,000 Characters Enhanced ITP Client Program for Password Encryption New version will be posted on the informational website and available for download as of April 30, 2007 New version must be used on June 18 - previous version will not work

29. June 18, 2007 System Release Display most recent Entity Information Section A will be expanded to include the most recent reporter name and address (if it has changed) since the submission date Five variations No change in reporter information Updated reporter information Original reporter is inactive with no successor Original reporter is inactive with a successor Original reporter is inactive with a successor, the successor is inactive

30. No change Reporter information is current

31. Original Reporter inactive with no Successor Reporter is inactive with no successor

32. Original Reporter inactive with a Successor Reporter is inactive with a successor Successor POC is provided if present

33. Original Reporter inactive with a Successor Reporter is inactive with a successor Successor POC is provided if present

34. Original Reporter inactive with a Successor, and the Successor is also inactive Reporter is inactive with a successor, and the successor is also inactive Successor POC is provided if present

35. June 18, 2007 System Release Limit Registration Renewal Grace Periods There will be a limit of three months or four (4) grace renewals, whichever is longer, in which the entity is permitted access to the system without actually renewing Once the limit is passed, the system will permit the user to renew only. There will not be a grace period provided to use the system while the renewal is mailed and processed Grace Period For Expired Entity Registrations The system considers an entity to be “inactive” once their registration expires. Report change notifications are not sent to inactive entities To prevent an entity with an expired registration from missing report change notifications, a 90 day grace period will be established

36. June 18, 2007 System Release Addition of another option to Automatic Reinstatement Data Element (IQRS and ITP) Currently, an entity can select only "yes" or "no" in response to whether a reinstatement is automatic at completion of the adverse action period Add a third response option: Yes Yes, with conditions (requires a Revision to Action Report when status changes) No

37. Automatic Reinstatement Options Now three response options

38. Other Recent System Improvements Historical Summaries Users can retrieve historical summaries of their queries and reports back to June 2000. Use entity name and specific date range for the search Limited to one-year increments within three years of the search date Query/Report Response Availability Available via IQRS for 45 days, previously only available for 30 days Timely Reporting Notice regarding timeliness of reporting included on the Report Verification Document (RVD)

39. NPDB - HIPDB New Initiatives Proactive Disclosure Service (PDS) Section 1921: expansion of the NPDB

40. Proactive Disclosure Service (PDS) The intent of PDS is to protect the public and improve the quality of health care by providing information to entities as soon as it is received by the Data Banks Average querier receives a new Data Bank report in 302 days Opens as a Prototype on May 1, 2007 Prototype status expected to last 18 months for evaluation purposes

41. The Current Query Process Hospitals, other health care entities, including MCOs, State and Federal agencies query the Data Bank by requesting information on a routine schedule A seamless, secure internet system permits a user to query one or both Data Banks Users query in preparation for reappointment or during the re-credentialing process (typically every 2 or 3 years) The query fee is $4.75 per name, per Data Bank

42. The PDS Process A subscription service that notifies subscribers of new information on any of their enrolled practitioners within one business day of Data Banks receipt of the information Notification is sent via email; the entity must log in to retrieve the information Offered as an alternative to and not a replacement of the current querying method Report format, information and data reported to the Data Banks will not change Can use PDS for NPDB, HIPDB or both Fee is $3.25 per enrolled subject / per year

43. PDS Enrollment Enrollment Confirmation: An enrollment confirmation confirms that a practitioner is enrolled in the PDS May be used to demonstrate compliance with accreditation standards Enrollment confirmations include Subject information PDS enrollment dates, and Enrollment status

44. PDS Enrollment When a practitioner is first enrolled in the PDS, the enrollment confirmation will include all reports on the practitioner to ensure the entity is aware of all existing reports in the Data Banks This is included in the price of PDS Enrollment confirmations for enrolled practitioners and previously enrolled practitioners whose enrollments have been cancelled within the last four years will be available, upon demand

45. Report Notification Entity receives email notification

46. Report Notification

48. Users always have access to all the active reports on a subject

49. Report Notification

50. Other PDS Characteristics Data Bank report availability: Report disclosures will be available on the IQRS for 45 days in PDF format All reports in the Data Banks for each enrolled practitioner will be available upon demand

51. Other PDS Characteristics Subscribing to the service: A 12-month subscription period for each enrollee (practitioner) The subscription expires on the last day of the same month of the following year i.e., all practitioners enrolled in May 2007 regardless of the exact date of enrollment will have a subscription expiration date of May 31, 2008

52. Section 1921 A provision of the Social Security Act as amended by Section 5(b) of the Medicare and Medicaid Patient and Program Protection Act of 1987, as amended by the Omnibus Budget Reconciliation Act of 1990. Enacted to provide protection to program beneficiaries from questionable health care practitioners and to improve the anti-fraud provisions of Medicare and Medicaid.

53. Section 1921 Notice of Proposed Rule Making Published in the Federal Register on March 21, 2006 Expected final in October 2007 Expands the NPDB Major reports Added by Section 1921 Adverse actions or findings by private accrediting organizations such as: NCQA URAC The Joint Commission The Commission on Accreditation of Rehabilitation Facilities

54. Section 1921 Adverse licensure actions taken against all health care practitioners Broader than issues related to professional competence and conduct Adds the same type of licensure actions currently reported to the HIPDB

55. Reportable: without Section 1921 NPDB Medical Malpractice Payments Adverse Actions (physicians and dentists) Licensure Clinical Privileges* Professional Society Membership* Medicare and Medicaid Exclusions (all practitioners) DEA Actions (all practitioners) *other practitioners may be reported HIPDB* Licensure Actions Medicare and Medicaid Exclusions and other exclusions from Federal or State Health Care Programs Health Care Related Criminal Convictions, or Civil Judgments Other Adjudicated Actions or Contract Terminations *Practitioners, Providers and Suppliers

56. Reportable: with Section 1921 NPDB Medical Malpractice Payments Adverse Actions (physicians and dentists) Licensure Clinical Privileges* Professional Society Membership* Medicare and Medicaid Exclusions (all practitioners) DEA Actions (all practitioners) *other practitioners may be reported HIPDB* Licensure Actions Medicare and Medicaid Exclusions and other exclusions from Federal or State Health Care Programs Health Care Related Criminal Convictions, or Civil Judgments Other Adjudicated Actions or Contract Terminations *Practitioners, Providers and Suppliers

57. Section 1921 Access Entities that are currently allowed to query the NPDB will have access to Section 1921 reports Entities given access to the NPDB through Section 1921 will be allowed to query ONLY for Section 1921 reports

58. Access without Section 1921 NPDB Hospitals and other Health Care Entities State Medical and Dental Licensing Authorities Professional Societies with formal peer review Practitioners (self-query only) Researchers (non-identifiable statistical information) HIPDB Federal and State Government Agencies Health Plans Practitioners, Providers and Suppliers (self-query only) Researchers (non-identifiable statistical information)

59. Access with Section 1921 NPDB & Section 1921 Hospitals and other Health Care Entities State Medical and Dental Licensing Authorities Professional Societies with formal peer review Practitioners (self-query only) Researchers (non- identifiable statistical information) Section 1921 Only State Medicaid Fraud Control Units Agencies administering Federal and State Health Care Programs U.S. Comptroller General U.S. Attorney General and other law enforcement officials

60. Reference Information Web Site - www.npdb-hipdb.hrsa.gov NPDB and HIPDB Guidebooks Interactive Training Brochures and Fact Sheets Statistics Annual Reports Instructions for Reporting and Querying Customer Service Center - 1-800-767-6732 (1-800-SOS-NPDB )

61. LCDR Shari W. Campbell, DPM, MSHS Policy Analyst Practitioner Data Banks Branch (301) 594-4251 scampbell@hrsa.gov Contact Information