Title IV of the Health Care Quality Improvement Act of 1986 (HCQIA), created the National Practitioner Data Bank (NPDB). The NPDB is a national clearinghouse and repository of information on medical malpractice payments and adverse actions taken against licensed healthcare providers. Hospitals and health systems with formal peer review are among the entities required to report to the NPDB.

The Health Resources and Services Administration (HRSA) publishes the NPDB Guidebook (Guidebook) which is a policy manual that provides an interpretation of NPDB requirements for entities with mandatory reporting obligations. The Guidebook states that the purpose of the NPDB is to function as a “flagging system that may serve to alert users that a more comprehensive review of the qualifications and background of a health care practitioner may be prudent.”

In October 2018, the HRSA updated the Guidebook for the first time since April 2015. The recent revisions to the Guidebook’s chapter on reporting requirements are significant because they provide clarification (and take a more expansive view) on the types of events that trigger reporting obligations.

Below are the top five new clarifications that all institutions with reporting obligations should keep on their radar as 2019 progresses.

  1. Quality Improvement Plans. If a quality improvement plan restricts a practitioner’s clinical privileges, is the result of a professional review action, concerns the practitioner’s professional competence or conduct, and is in place longer than 30 days, the plan may be reportable.
  2. Leaves of Absence. If a leave of absence while under investigation restricts privileges, it is reportable. If a practitioner can take a leave of absence without affecting his or her privileges, and his or her privileges remain intact during the leave of absence, the leave of absence is not reportable.
  3. Restrictions on Privileges. A restriction imposed on an entire class of physicians (i.e., all new surgeons are required to operate with a qualified first assistant) is not a restriction of privileges that is reportable. However, if such a requirement is imposed on a licensed healthcare provider as part of a professional review action about professional competence and conduct, and runs more than 30 days, the action is reportable as a restriction of clinical privileges.
  4. Lapses in Privileges. If the Medical Executive Committee recommends that a physician not be reappointed, and the physician’s appointment term ends while the parties are waiting for a hearing, the lapse is reportable.
  5. Informal Agreements Not to Exercise Privileges. An agreement not to exercise privileges is a restriction of privileges. Any restriction of privileges while under investigation, temporary or otherwise, is considered a resignation and must be reported.