What Every Credentialing Team Needs to Know About NPDB Reporting

Credentialers may not complete NPDB reporting for their organizations, but they absolutely benefit from it.

Think of the National Practitioner Data Bank (NPDB) as healthcare’s “background check.” It was established to prevent problematic practitioners from moving between organizations without disclosure of past performance issues or disciplinary actions. 

Credentialers routinely complete NPDB queries to verify providers in their organization, which means they’re depending on others to have accurately completed NPDB reporting.

In this article, we’ll break down what credentialing teams need to know about NPDB reporting, common challenges, and how best practices and technology can help maintain compliance with ease.

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What NPDB Reporting Covers

According to the Department of Health and Human Services (HHS), NPDB information is intended to be used in combination with information from other sources in making employment, certification, licensure, clinical privilege, affiliation, or other decisions.

NPDB reporting is required for healthcare practitioners, entities, providers, and suppliers. Here’s a look at what must be reported:

• Adverse Actions: Reports negative actions or findings related to professional competence or conduct to licensing boards, hospitals, or professional societies.
• Malpractice Payments: Tracks settlements or judgments related to provider malpractice.
• Exclusion Checks: Lists providers barred from participating in federal (Medicare) or state (Medicaid) healthcare programs.
• Controlled Substance Actions: The DEA is required to report controlled substance registration actions against practitioners.
• Convictions: Federal and state agencies and prosecutors are required to report care-related civil judgments, criminal convictions, and adjudicated actions.

As you can see, this information is very different from what is collected as part of CAQH credentialing. The CAQH profile is designed to collect provider demographic data that can be accessed by payers and organizations to streamline provider healthcare credentialing. The NPDB strictly focuses on misconduct and adverse event data, making it an indispensable tool for risk management.

Who Is Responsible for NPDB Reporting?

Credentialing, or medical staff services, teams are typically part of the NPDB reporting process, even though they may not file reports themselves.  

Roles Involved in NPDB Reporting

Entities Required to Report

NPDB reporting is required by law under: Title IV of Public Law 99-660, the Health Care Quality Improvement Act of 1986 (Title IV); Section 1921 of the Social Security Act (Section 1921); Section 1128E of the Social Security Act (Section 1128E); and their implementing regulations found at 45 CFR Part 60. The following are the types of entities required to report:

• Medical malpractice payers
• Hospitals and other health care entities
• Professional societies
• Health plans
• Peer review organizations
• Private accreditation organizations
• Federal government agencies
• State law enforcement agencies
• State Medicaid fraud control units
• State agencies administering or supervising the administration of a state health care program
• State licensing and certification authorities (including state medical and dental boards)

Common Mistakes in NPDB Reporting

Common mistakes in NPDB credentialing can expose healthcare organizations to legal risk, regulatory penalties, and loss of accreditation. Credentialing teams are on the front lines of healthcare compliance, so knowing what not to do is just as important as knowing what to do. Here’s a detailed look at the most frequent errors.

Missing the 30-Day Deadline

The NPDB requires that reports be submitted within 30 calendar days of the reportable event or payment. Late or inaccurate NPDB reporting may result in fines, sanctions, or loss of liability immunity in malpractice cases.

Here’s where many organizations go wrong:

• Delaying reporting while waiting for internal investigations to conclude.
• Confuse the start date of the 30-day window, especially with ongoing cases. You should start counting from the date the final action is taken, not when an appeal ends (unless it stays the action).

Failing to Report Required Actions

The list of required actions at the beginning of this article seems very black and white, but as anyone in healthcare compliance knows — there are usually many shades of gray. To avoid some of the questions, train staff regularly to recognize reportable events and consult legal counsel or the NPDB guidebook when unsure.

Here’s what many organizations fail to report:

• Privileging actions lasting longer than 30 days. 
• Voluntary resignations during an investigation or to avoid one.
• Malpractice payments made by an insurer, even if there’s no admission of fault.
• Thinking “voluntary resignation” is always non-reportable.
• Privilege restrictions, which are confused with HR disciplinary actions (which aren’t reportable).

Inaccurate or Incomplete NPDB Reports

Errors such as incorrect practitioner identifiers, vague or misleading narratives, or misclassified action types can lead to confusion, disputes, or even formal challenges from the affected provider. These mistakes may result in the NPDB rejecting the report, requiring time-consuming corrections, or triggering investigations into the organization’s compliance practices.

Here’s where organizations go wrong:

• Failing to correct errors in a previously submitted report.
• Forgetting to update reports when an appeal modifies the action.
• Not taking action if the event turns out not to be reportable.

Lack of Standardized Processes

Some actions slip through the cracks when organizations don’t have NPDB reporting processes and procedures for flagging adverse events. 

Here’s how organizations go wrong:

• Peer review committees or department chairs fail to notify the team in charge of NPDB reporting.
• Legal or compliance handles investigations without looping in credentialing.
• No clear assignment of NPDB reporting responsibilities, so everyone assumes another department is handling it.
• Overreliance on informal or verbal actions, such as when a provider is asked to “step back” from some duties.

Failing To Maintain Documentation

As everyone in healthcare compliance knows, if it isn’t documented, it didn’t happen. NPDB reports may be challenged by practitioners, and external audits may review your organization’s reporting history. These make it critical to retain supporting documentation, like peer review findings or investigation memos.

Here’s where organizations go wrong:

• Discard records before the recommended five to seven years.
• Fail to establish a reporting policy that is aligned with NPDB guidelines.
• Maintain sloppy, incomplete, or inaccurate records that are unusable.

Simplify NPDB Reporting And Compliance With Technology

To maintain compliance, today’s healthcare teams need centralized NPDB credentialing. A single location for provider data management and direct access to continuous NPDB queries provides critical transparency across departments. 

MedTrainer’s comprehensive healthcare credentialing software enables NPBD authorized agents to access reports directly within the platform to eliminate the back-and-forth and re-uploading that comes with manual queries. Automated exclusions monitoring and license verification keep your organization current on potential risks before they become an issue.