Crucial Need for NPDB Credentialing

Health organizations must complete National Practitioner Data Bank or NPDB credentialing to maintain compliance with federal regulations. This confidential clearinghouse primarily aims to safeguard public interest and healthcare quality while reducing fraud and abuse. This process can become quite arduous, especially for large organizations querying multiple health practitioners, entities, and suppliers.

Additionally, this type of credentialing is just one step of the larger credentialing process for healthcare providers, and if left incomplete, it can lead to several downstream issues. Therefore, understanding NPDB credentialing is essential for any health organization.

What Is NPDB Credentialing?

NPDB credentialing involves centrally verifying the background and qualifications of a healthcare provider, supplier, or another entity. The NPDB system is a confidential querying system that alerts or flags an organization that there may be performance issues with the person or entity they are verifying. Therefore, organizations should not use the NPDB as a primary source of verifying background and credentials; rather, it should be used with other primary source verification tools. Typical organizations that may query the NPDB are:

• Hospitals
• Professional healthcare organizations or societies
• Boards of medical examiners
• State board of licensing
• Attorneys
• Drug Enforcement Agency
• Medical malpractice payers

Most of these organizations must also report any adverse actions to the NPDB. Organizations must register for an account, submit the required documentation, and receive authorization before searching the National Practitioner Data Bank.

Many health systems have multiple entities, such as hospitals, outpatient centers, and clinics, where numerous providers may practice or provide medical services. Instead of querying the NPDB numerous times, these large organizations typically benefit from centralized credentialing through a Centralized Verification Organization (CVO). A CVO gathers information and verifies providers’ credentials through multiple sources on behalf of their own or other organizations, ultimately granting privileges to the specific health system. For example, a surgeon may provide services at multiple health facilities within the same health system, like seeing patients at a clinic or performing surgeries at a handful of outpatient or inpatient centers. In lieu of the health system individually verifying the surgeon’s credentials and privileges for all these facilities, they may choose to use centralized credentialing, where they query the NPDB once.

Some health organizations elect an authorized agent to search the database on its behalf to streamline its credentialing processes. Authorized agents must adhere to strict guidelines and search the database separately for each entity it represents. Query reports must not be disclosed to another entity the authorized agent represents.

What Information Does NPDB Verify?

The database flags and alerts health organizations of possible adverse actions related to the background and qualifications of the person or entity they are searching for. The alert reveals information about unfavorable actions related to privileges, exclusions, licensure, professional memberships, and law enforcement. Interestingly, the database only releases information that specific health organizations can access based on their authorized registration. Examples of NPDB-verified information are:

• Federal and state certification and licensure actions
• Medical malpractice claims
• Negative actions against clinical privileges
• Disciplinary actions related to accreditation and peer review organizations
• Criminal or civil convictions and judgments
• Medicare & Medicaid exclusions
• Unfavorable actions from a professional health organization

The NPDB report may also provide information regarding fraud, waste, and abuse claims against the provider or entity. Examples include beneficiary inducement, anti-kickback, and physician self-referral violations. Fraudulent medical claims, misconduct, and Emergency Medical Treatment and Labor Act (EMTALA) violations are also reported.

How Often Should Healthcare Organizations Query the NPDB?

There are a few instances when a healthcare organization may inquire into the NPDB, including:

1. New provider: When a new provider is offered employment, a small portion of their credentialing process entails NPDB credentialing. 
2. New entity: A health organization may complete an NPDB query when opening new facilities or working with new suppliers, vendors, or other entities.
3. Renewal: Federal law mandates that health organizations complete NPDB credentialing every two years. 

The NPDB offers two types of search services, including a one-time and continuous query. As the name implies, a one-time query provides a single report of a provider or organization at that specific point in time. The health organization will not be notified of new reports or alerts after this initial date. A continuous query permits an organization to receive an initial query and then any subsequent updates over a year. The continuous query benefits most organizations by almost instantly notifying them of any changes, providing a monthly summary report for each enrolled practitioner, and helping streamline the re-credentialing process.

Streamline Your Process With Credentialing Software

NPDB queries are just one part of the very tedious credentialing process. Many healthcare organizations have turned to credentialing software to better manage the required verifications, data, and applications. Credentialing software automates redundant manual tasks, such as NPDB queries, so that credentialers can spend their time on other parts of the process. It also keeps all of a provider’s information together in one place with visibility for those who need access.

MedTrainer’s credentialing platform saves time with exclusions monitoring, re-credentialing reminders, and automated license verifications. 

Explore more of MedTrainer’s products and the many benefits of using an all-in-one compliance platform today.