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June 4, 2013

Incomplete Office of Inspector General Exclusion Reports Undermine Usefulness of the National Practitioner Data Bank

Reports Are Critical for Background Checks on Doctors and Other Health Providers

WASHINGTON, D.C. – Incomplete information in as many as 50,000 reports provided to the National Practitioner Data Bank (NPDB) by a key federal agency undermines the usefulness of the data bank, which serves as a national clearinghouse of transgressions by physicians and other health care providers that are critical to employment and credentialing decisions, a new Public Citizen report shows.

Because of problems with the reports provided to the NPDB by the Office of Inspector General (OIG) at the U.S. Department of Health and Human Services (HHS), entities using the data bank to conduct background checks may not learn that health care providers have been excluded from Medicare or Medicaid for such things as substandard services and fraud.

About 50,000 of the OIG exclusion reports in the data bank may lack sufficient practitioner identifying information to assure that such reports – which bar incompetent and convicted practitioners from participating in federal health care programs – are provided to the 17,000 users of the NPDB (including hospitals, managed care organizations and state licensing boards) when they query the NPDB to conduct background checks, Public Citizen’s report, available at http://www.citizen.org/hrg2132, shows.

“Making OIG exclusion reports more accessible to users of the NPDB would improve patient safety and program integrity in the health care industry by ensuring that the serious provider problems that caused the exclusion in the first place are known to potential employers such as hospitals or HMOs and to medical boards when they do background checks on these individuals,” said Dr. Sidney Wolfe, director of Public Citizen’s Health Research Group. “Unless these exclusion reports are available, users of the NPDB, such as hospitals or HMOs, could inadvertently employ an excluded health care provider because the OIG exclusion did not show up when they queried the NPDB.”

Run by HHS, the NPDB is a national clearinghouse of medical malpractice payment reports, hospital and health care regulatory boards’ disciplinary actions, as well as OIG exclusions. More than 50,000 employment, credentialing and licensure decisions annually are affected by new information provided by the NPDB, based on estimates from an HHS-funded study by Northwestern University.

Incomplete and inaccurate information relating to the identity of practitioners in OIG exclusion reports in the NPDB makes it more difficult to match queries with exclusion reports. This difficulty was documented in a Public Citizen analysis of the NPDB Public Use File and research done by NPDB staff on Public Citizen’s behalf. It was determined that only 47 percent of the OIG exclusion reports in the NPDB had been disclosed to people making queries of the NPDB; in contrast, 71 percent of medical/osteopathic board disciplinary reports in the NPDB had been disclosed, while 85 percent of hospital disciplinary reports had been disclosed. The inadequacy of identifying information in OIG exclusion reports submitted to the NPDB is the most likely explanation for this discrepancy.

Furthermore, an NPDB staff analysis of a Public Citizen-identified sample of 417 OIG exclusion reports involving physicians found that 80 of the exclusion reports included inaccurate information. An August 2000 OIG report cited a survey of Medicare staff who raised concerns regarding the timeliness, completeness and reliability of exclusion data.

Problems with OIG exclusion reports were a factor in the decision by the Centers for Medicare and Medicaid Services (CMS) to create its own exclusion database, which contains OIG exclusion data that has been reviewed and corrected, if possible, by CMS. As of March 2013, a CMS error file contained nearly 2,000 unusable OIG exclusion reports. Errors included problems with Social Security numbers and birthdates.

Apparently in anticipation of this Public Citizen report, the OIG advised the health care industry on May 8, 2013, to use the OIG exclusion list on the OIG website rather than the NPDB for identifying excluded providers. This warning not only will deprive the health care industry of “one-stop” background checks, but also will deprive the industry of more than 10,000 exclusion-related reinstatement reports that are in the NPDB but have been purged by OIG from its own online exclusion database.

Although 1996 legislation mandated the use of a National Provider Identification Number (NPI) by 2007, the OIG only recently, on May 8, 2013, made a commitment to use NPIs, unacceptably limiting their use to only 16 percent of the 50,000 exclusions in its database – the ones occurring after 2009. NPIs are useful because they facilitate accessing reports on the same practitioner in the NPDB. Public Citizen recommends that the OIG improve the quality of its exclusion reports by immediately using NPIs and other identifying information for all exclusion and reinstatement reports.

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