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. Completing NPDB continuous queries on all health practitioners, entities, and suppliers within an organization is just part of the overall credentialing process that safeguards healthcare organizations and their patients.

The benefits of NPDB credentialing include preventing unqualified individuals from treating patients, reducing liability from negligent hiring, and ensuring compliance with federal standards and funding. Today’s healthcare credentialing software is simplifying the entire process, including NPDB credentialing. In this article, I’ll explain more about NPDB credentialing and how to streamline the process with technology.

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 organizations report into and query information from to better understand potential performance issues with a person or entity they may employ. Organizations should not use the NPDB as a primary source of verifying background and credentials, but it is a valuable check in addition to other primary source verification tools.

NPDB Organizational Query

Organizations must register for an account, submit the required documentation, and receive authorization before searching the National Practitioner Data Bank. 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

Health systems who have multiple entities, such as hospitals, outpatient centers, and clinics, where numerous providers may practice or provide medical services may 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. 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.

NPDB Self Query

Providers conduct NPDB self-queries to proactively manage their professional standing, maintain transparency, and stay compliant with credentialing requirements. An NPDB self query gives the provider access to medical malpractice payments, adverse licensure or privileges actions, or judgements and convictions found. Self queries are mailed directly to the provider and require a signature upon delivery.

NPDB Reporting

Most of the organizations querying the NPDB must also report any adverse actions through NPDB reporting in credentialing. Since other healthcare organizations are relying on the information available through NPDB, completing these reports accurately is important to the entire healthcare industry. Credentialing, or medical staff services teams are typically part of the NPDB reporting process, even though they may not file reports themselves.  

What Information Does NPDB Verify?

NPDB credentialing 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. This is why many providers choose to complete a NPDB self query – so they are aware of the information being provided. 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?

The NPDB offers two types of search services, including a one-time and continuous query. An NPDB continuous query is recommended to ensure patient safety and protect organizations. It provides almost instant notification of any changes, provides a monthly summary report for each enrolled practitioner, and helps streamline the re-credentialing process. Continuous NPDB queries permit an organization to receive an initial query and then any subsequent updates over a year. 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. NPDB continuous queries for all providers can be very time consuming without healthcare credentialing software, so that’s why many healthcare organizations choose one-time queries at these critical points:

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. 

Make NPDB Continuous Queries Attainable With Credentialing Software

NPDB queries are just one part of the very tedious credentialing process. Many healthcare organizations use NPDB credentialing software to better manage the required verifications, data, and applications. A robust credentialing software like MedTrainer offers direct integration so you can pull a NPDB report right within the platform, allowing for faster and more efficient decision making in hiring and granting privileges to providers. It also erases the need to manually pull a report and upload it separately.

Provider data management is simpler than ever with MedTrainer. All provider information is together in one place, with activity automatically tracked – including NPDB queries. The report automatically pulls into MedTrainer’s platform and is saved with the provider’s documents. This puts all information, documents, exclusion status, enrollment stats, and more in one place for easy access and complete visibility. 

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