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Mum’s the Word: Are Hospitals Underreporting Problematic Providers?

November 1, 2023

It wasn’t an out-and-out lie, really. You just failed to mention a few details; that’s all! This may be representative of the internal dialog taking place within the heads of more than a few hospital managers these days as they attempt to rationalize a reporting “oversight” on their part. On the one hand, hospitals are required to provide detailed reports pertaining to their clinical practitioners—including the less flattering aspects; on the other hand, fully complying with the rules could negatively impact the hospital’s overall operation. At least, that seems to be the thinking.

The Requirement Revisited

One of the agencies falling under the aegis of the U.S. Department of Health and Human Services (HHS) is the National Practitioner Data Bank (NPDB). Hospitals are required to provide the NPDB with information concerning the clinicians who practice at their facility. The agency wants to know, among other things, if there are problematic providers who have slipped through the cracks of scrutiny and who may therefore prove potentially harmful from a patient care and safety standpoint.

In checking the NPDB website, here is what hospitals are expected to include in their reports to the federal data bank, pertaining to their medical staff:

  • Medical malpractice payments
  • Adverse clinical privileges actions
  • Adverse professional society membership actions
  • State licensure and certification actions
  • Federal licensure and certification actions
  • Negative actions or findings by a peer review organization
  • Negative actions or findings by a private accreditation organization
  • Exclusions from participation in a Federal or state health care program (including Medicare and Medicaid)
  • Other adjudicated actions or decisions
  • Health care-related civil judgments and criminal convictions in Federal or state court

So, obviously, the NPDB wants to keep abreast of potentially problematic providers operating within the confines of our nation’s hospitals. The agency’s website contains detailed instructions on how the required information is to be reported, amended, corrected, etc. The problem is that some hospitals are not complying to the extent expected and required.

A Report of Underreporting

The problem is that doctors move around. If they get into trouble in one state due to a civil judgment or license revocation, they simply move to another state, get a license in the new jurisdiction and set up shop. The medical facilities in the new state may be unaware of any previous problems facing the doctor who is now submitting a request for hospital privileges. The questions is, how hard is the hospital looking into this new provider’s past?

There are over 255,000 doctors in the NPDB going back to 1990. Of these, 17,008 lost their license, and a little over 8,700 faced disciplinary action. But do these figures accurately reflect the true numbers of adverse actions for the doctors in the database? According to the U.S. Health Resources and Services Administration, about 45 percent of hospitals have never submitted a single report involving adverse actions taken against a doctor’s privileges in the 33 years that the data bank has been in operation. How could this be?

According to an Oct 30 article in Gothamist, which investigated hospital underreporting:

One obvious reason for underreporting: If you are a hospital, employing a doctor, or if you are a colleague of a doctor who has done something shady, there are reputational disadvantages to reporting them. There’s really no enforcement mechanism for these reporting requirements . . . if a hospital fails to report a misbehaving doctor to the data bank, practically speaking, no one is going to catch that.

In addition, according to the NPDB website, hospitals are required to report long-term restrictions on a physician’s privileges, but only if they exceed 30 days. This may act as a loophole, letting hospitals off the hook, from a reporting perspective, if the 30-day threshold is not met. According to Becker’s Hospital Review, there are a couple other factors that allow hospitals to limit their reporting in this area or to suppress such reporting:

  • Hospitals can often prevent malpractice lawsuits from being added to a physician’s record by removing their names from settlement agreements, even if the physician is a named defendant.
  • Provider resignations have to be reported only if a hospital is officially investigating a physician when they resign or if a physician resigns to avoid an official investigation, which is difficult to prove. Voluntary resignations are not required to be reported. Hospitals are known to warn physicians to resign before an investigation is launched into their conduct to avoid being reported to the data bank.

While there may exist loopholes and little enforcement, hospitals would do well to fully report adverse actions associated with its privileged providers. It’s the law, and patient safety should always be paramount.

With best wishes,

Chris Martin
Senior Vice President—BPO

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