Big Brother gets in the data collection business

Provider self-disclosure protocol also is published

Big Brother wants a closer look at what’s going on in the fraud and abuse arena and wants to start a data bank of that very information.

The Health and Human Services Office of the Inspector General (OIG) in Washington, DC, proposed a rule in the Oct. 30, 1998, Federal Register to implement a national health care fraud and abuse data collection program.

The Healthcare Integrity and Protection Data Bank (HIPDB) is a provisional requirement of the Health Insurance Portability and Accountability Act of 1996 and will report and disclose certain final adverse actions taken against health care providers, suppliers, or practitioners.

Database of adverse actions

HIPDB also will act as a database of final adverse actions taken against health care providers, suppliers, or practitioners. (For more information on the OIG’s focus on fraud and abuse in 1999, see cover story.)

The final adverse actions include:

1. civil judgments against a health care provider, supplier, or practitioner in federal or state court, related to the delivery of a health care item or service;

2. federal or state criminal convictions against a health care provider, supplier, or practitioner related to the delivery of a health care item or service;

3. actions by federal or state agencies responsible for the licensing and certification of health care providers, suppliers, or practitioners;

4. exclusion of a health care provider, supplier, or practitioner from participation in federal or state health care programs;

5. any other adjudicated actions or decisions that the Health and Human Services Secretary establishes by regulations.

The range of reportable final adverse actions indicates that Congress intends to interpret the term "health care fraud and abuse" broadly, the proposed rules states. It says that reportable final adverse actions include, "actions related to provider, supplier, and practitioner practices that are inconsistent with accepted sound fiscal, business, or medical practices, directly or indirectly, resulting in: unnecessary costs to the program; improper payment; services that fail to meet professionally recognized standards of care or that are medically unnecessary; or adverse patient outcomes, failure to provide covered or needed care in violation of contractual arrangements, or delays in diagnosis or treatment."

The proposed rule intends to avoid duplication with the reporting requirements for the National Practitioner Data Bank (NPDB), which contains licensure and malpractice information. Therefore, only NPDB state licensing information effective after Aug. 21, 1996, will be included in the HIPDB.

The proposed rule also notes that some settlements, such as those including no admissions or finding of liability, will be excluded from the reporting process.

Information to come with a price

Groups that will have access to the new data bank system include federal and state government agencies, health plans, and self-queries from health care suppliers, providers, and practitioners. An undetermined fee will apply to most requests.

Federal agencies are exempt from the fees, and a free copy of every record automatically will be provided to each health care provider, practitioner, or supplier who is the subject of a report.

The proposed rule requires that information be submitted to the HIPDB within 30 calendar days from the date the final adverse action was taken, the date when the reporting entity became aware of the final adverse action, or by the close of the entity’s next monthly reporting cycle, whichever is later.

To view a copy of the proposed rule, visit the Federal Register’s Web site: http://www.access.gpo.gov/su_docs/aces/aces140.html.