NPDB Stuff

[Sushirolls]

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Getting some messages from another person here on SDN. Questions I don't know the answer to.

My understanding is the NPDB is only able to receive reports on lawsuits paid out. The person messaging me states there are other reasons, too. This person is likely a new attending or a resident level seeking insurance paneling for a practice.

I have received DMs wondering if:

...a denial of initial application for enrollment in an insurance is reportable to NPDB IF it's due to professional incompetence or misconduct.

What does that exactly mean? Is this with regard to your previous employer if let's say you verbally harass a nurse or patient?

Please help me respond to this person's query. I believe they might have had an insurance application denial, and now wondering if it will be reported to the ol' NPDB.

 

[FlowRate]

I have no clue, but ChatGPT looked it up and this is what it said, FWIW:

Your understanding of the NPDB is a little too narrow. It isn't limited to malpractice payouts.

For physicians/dentists, insurance panel/network participation can count as "clinical privileges" for NPDB purposes. If an insurer/health plan uses a professional peer-review process and denies an initial application for panel membership because of the physician's professional competence or professional conduct — specifically conduct that adversely affects or could adversely affect patient health/welfare — that denial can be reportable.

It does NOT mean that every insurance denial gets reported. A denial because the panel is closed, they don't need another psychiatrist in the area, you don't meet an objective credentialing threshold, etc., generally isn't reportable as an adverse clinical-privileges action.

As for "misconduct," it can include behavior rather than strictly clinical errors. The NPDB Guidebook actually gives an example of an HMO terminating a physician for sexually harassing a nurse and revoking his network participation through peer review; NPDB says the network-participation action is reportable. So harassment could potentially qualify if the reviewing entity determines that the professional conduct affected or could affect patient welfare. It isn't simply "my prior employer wrote me up for being rude," though.

So if this person had an initial insurance application denied, the key questions would be: Was this an actual peer/professional-review decision? Was the stated basis professional competence or professional conduct affecting/could affect patient welfare? Or was it merely an administrative/eligibility/business denial?

Also, malpractice isn't the only other thing in the NPDB. Licensure actions, adverse clinical-privileges actions, certain health-plan actions, exclusions, health-care-related judgments/convictions, etc. can all appear there.

 

[comp1]

I'm not understanding this. If it's reported, it's reported. You can't control that, you can only explain if someone ever asks. Why is this person asking?

 

[Sushirolls]

I believe the question is more based in what gets reported, and how it might apply to their insurance application denial.