Question

Lesson 3: Managed Care Reimbursement Structures

Upon completion of the Required Readings, write a thorough, well-planned narrative answer to the following discussion question. Rely on your Required Readings and the Lecture and Research Update for specific information to answer the discussion question, but turn to your original thoughts when asked to apply, evaluate, analyze, or synthesize the information.  Your Discussion Question response should be both grammatically and mechanically correct, and formatted in the same fashion as the question itself. If there is a Part A, your response should identify a Part A, etc.  In addition, you must appropriately cite all resources used in your responses and document in a bibliography using APA style.

Discussion Question 1 (25 points)

Part of the credentialing process for physicians includes query of the National Practitioner Data Bank (NPDB) and in the future, the Healthcare Integrity and Protection Data Bank (HIPDB). Discuss what these data banks are, how they differ, and under what circumstances a MCO can query these data banks. (25 points) (A 1½-page response is required.)

Answer 1

National Practitioner Data Bank (NPDB)

The National Practitioner Data Bank (NPDB) is a web-based repository. It contains the information related to the health care practitioners, providers, and suppliers, such as information on medical malpractice payments and certain adverse actions.

NPDB was established by Congress in 1986. NPDB acts as a workforce tool. As it contains the information on medical malpractice payments and certain adverse actions, it can prevent practitioners from moving state to state without disclosure or discovery of previous damaging performance. The NPDB reports are confidential and available only to the people and organizations who are subjects of these reports.

The mission of NPDB is to improve the quality of health care, protect the public, and reduce health care fraud and abuse in the country.

The information is also available for the MCOs upon request as they perform peer review functions. The NPDB also made it mandatory for the hospitals to query the Data Bank as part of the application process for practitioners.

Healthcare Integrity and Protection Data Bank (HIPDB)

In 1996 as per the Health Insurance Portability and Accountability Act of 1996 a new national data bank for the healthcare personnel’s was started as the Healthcare Integrity and Protection Data Bank (HIPDB). Reporting of data to the Healthcare Integrity and Protection Data Bank (HIPDB) started November 22, 1999. The main purpose of the creation of HIPDB was to combat fraud and abuse in health insurance and health care delivery. The information like civil judgments, criminal convictions, or actions by federal or state licensing agencies against a health care provider, supplier, or practitioner related to the delivery of a health care item or service is entered into the HIPDB.

The information in the HIPDB and NPDB may overlap sometimes. Apart from the NPDB, the HIPDB also has data relating to the exclusion of a health care provider, supplier, or practitioner from taking part in federal or state health care programs. The data about any physicians or healthcare provider must be reported to both the HIPDB and the NPDB. The data about reports on medical malpractice payments, clinical privileges actions, and professional society membership actions are available only in NPDB and data about civil judgments and criminal convictions are present only in the HIPDB.

The MCOs are also supposed to report the actions they take against affiliated practitioners that affect their clinical privileges for more than 30 days to the Data Bank like the hospitals.

The Data Bank has the basic aim to help protect patients from poorly performing health care practitioners, like physicians and dentists. The reports by the MCOs can be used by the health care organizations and licensure boards to review the practitioners. While performing a practitioners competency assessment they rely upon these databases to protect patients from poor performers. Any reportable acts by the practitioners in the MCOs will also be reported to the Data Bank.

If an MCO needs to be entitled to HCQIA immunity, it must report certain adverse actions against providers to the National Practitioner Data Bank (NPDB).

The MCOs will engage in effective credentialing as a part of the positive marketing purposes as they can attract more consumers and best health care professionals.

References:

1. The Data Bank – NPDB & HIPDB - NCSBN

2. https://www.ncsbn.org/0113_IRE_KRussell.pdf

3. https://oig.hhs.gov/oei/reports/oei-01-99-00690.pdf  

4. https://www.law.uh.edu/healthlaw/perspectives/Fraud/991210Fighting.html

5. https://physiciansnews.com/2001/06/17/managed-care-credentialing-of-physicians/  

6. https://www.npdb.hrsa.gov/topNavigation/aboutUs.jsp