New data bank rolls out

But hospitals cannot access HIPDB’s information

The federal Department of Health and Human Services (DHHS) was projected to roll out its new Healthcare Integrity and Protection Data Bank (HIPDB) by May 19 or soon thereafter. Mandated by the Health Insurance Portability and Accountability Act of 1996, HIPDB requires the following entities to report fraud-and-abuse related adverse actions against providers, practitioners, and suppliers:

    • health plans;
    • government agencies, including the Department of Justice, DHHS, and others that administer payment for the delivery of health care services;
    • federal and state agencies responsible for licensing, such as state medical boards;
    • state law enforcement agencies;
    • state Medicaid fraud control units.

The HIPDB is geared more toward health plans and integrated delivery systems than toward hospitals. In fact, it cannot be accessed directly by hospitals. It will be more sweeping in what it collects than the National Practitioner Data Bank (NPDB). HIPDB will track these kinds of final adverse actions:

    • civil judgments;
    • federal or state criminal convictions;
    • actions by federal or state licensing agencies;
    • exclusions from federal or state programs.

Data bank reports can be accessed only by entities entitled to query HIPDB: federal and state agencies, health plans, and CVOs authorized to query on behalf of health plans, but not hospitals, except in the case of self-query by hospitals that are reported there. Information there can be used against a physician in decisions regarding prosecution, contracting, or credentialing. The doctor’s name remains in the data bank forever. Even though you cannot access it directly, our experts recommend that, once it is up and running, you "piggyback" on a health plan and get your information that way.

The HIPDB is modeled on the NPDB and was launched by the same federal agency, the Health Resources Services Administration, Bureau of Health Professions, Division of Quality Assurance. There may be some coordination between the two data banks, and queries submitted to the HIPDB by health plans will be processed by both HIPDB and the NPDB.

State licensing board actions reported to the NPDB prior to August 1996 will not be in the HIPDB, but all subsequent state licensing board actions reported to the NPDB will be transferred to the HIPDB. Thus, the HIPDB will hold information as soon as it is operational; the NPDB was empty for a substantial length of time after it opened in 1990.

The HIPDB will contain immunity and confidentiality provisions identical to those of the NPDB, so credentialing committees will be able to adapt to its forms and terminology easily. You can read the proposed HIPDB regulations in the Federal Register [63 Fed Reg 58,341 (Oct. 30, 1998)]. Also, see HIPDB’s Web page at http://www.hrsa.dhhs.gov/bhpr/dqa/hipmain.htm. (For additional information on NPDB and HIPDB, see Hospital Peer Review, January 1999, pp. 5-7.)

HMOs will query the HIPDB when they make credentialing decisions regarding practitioners they hire. That reverses the typical credentialing scenario, in which health plans and managed care organizations rely upon the credentialing decisions of hospitals.

"It turns the credentialing flow on its head," says Mark Kadzielski, JD, a partner in the Los Angeles law office of Epstein Becker & Green. "It used to be that where, for example, a health system had three hospitals and an HMO, the HMO always piggybacked on data from the hospital. HMOs relied on the fact that a doctor was on the staff of a hospital. They would say, As long as you’re a member in good standing of that acute care hospital medical staff, you can be in our HMO.’ That’s because hospitals were known to have state-of-the-art primary credentialing systems." As long as a doctor was on that staff, the HMO assumed he was thoroughly and properly credentialed and subject to extensive peer review.

"Now," says Kadzielski, "the HMO has access to the HIPDB and all its dirt, but hospitals do not. Now the HMO is the repository of information on dirty doctors, and hospitals need to find out from HMOs what’s going on."

With HMOs credentialing doctors, and doctors applying to hospitals as members of HMOs, hospitals will expect that the doctor has been screened through the HIPDB and that if any dirt surfaced, the HMO will share it with the hospital.

But should you rely on those secondary sources? No, say most experts. Do your own primary verifications. HIPDB should be only one of the several sources you look to for credentialing.