Should we pull the providers NPDB reports or request the provider to do a self query?

This has been a common question recently.  Therefore, I wanted to relay the information for your review.

According to the information I have researched, in order to pull NPDB reports you must be a "Healthcare Entity".  A "Healthcare Entity" is defined as:

  • A board of medical examiners or other state licensing board
  • A hospital
  • An entity that provides health care services and and follows a formal peer review process to further quality healthcare
  • A professional society that that follows a formal peer review process to further quality healthcare.

Most firms utilize the third definition to determine eligibility as they “provide health care services".  But, in order to meet that requirement, there has to be a “formal peer review” process for the purpose of “furthering quality heath care”.

I feel the “providing health care services” and “furthering quality health care” can be argued and possibly in your favor.  But, the “formal peer review” process can be a bit problematic.  From my understanding and speaking with others, this is understood to be a formal process that is reviewed by an actual physician (or mid-level depending on type of provider).  I know of some firms that have went so far as to hire a Medical Director that actually reviews every NPDB so they can bolster their argument in the event an investigation ever occurs.  Then again, I am sure others can argue this in the direction where a credentialing expert is a peer and they have a formal process to review them.  I can’t really speak to the success of failure of either argument though. 

The problem is the penalty is $11,000 per violation and it is retroactive back to every NPDB ever pulled.  That being the case, it can be extremely damaging in the event of losing an investigation.

I don’t want to make a mountain out of a mole hill.  But, I do want to do everything I can to make sure you are as protected as possible and pass on whatever information or “hot topic” I come across that is concerning.  For whatever reason (which there can likely be many), this one has been coming up more and more.