New federal fraud data bank locks out hospitals
Healthcare Integrity and Protection Data Bank places hospitals at the mercy of health plans and HMOs
The Healthcare Integrity and Protection Data Bank (HIPDB) unveiled by the Department of Health and Human Services’ Office of Inspector General (OIG) Oct. 26 will provide health plans — but not hospitals — with information on final adverse actions taken against health care providers. Critics say that by shutting out hospitals, the data bank may shift the balance of power in health care too far in the direction of health plans.
In the current environment, health plans typically turn to hospitals for information about physicians. But the HIPDB is about to turn that relationship on its head, says Mark Kadzielski, the partner in charge of the West Coast health care practice of Akin, Gump, Strauss, Hauer & Feld in Los Angeles. "Now, hospitals will be waiting for the health plan to make a decision about the doctor and the hospital will be the last to know," he asserts.
"HMOs are not prepared to deal with this," he warns, "or to deal with the fact that they now will be the focus of all of this information and will have to make some tough decisions."
"Hospitals have a huge compliance obligation, and this databank will contain lots of dirt," Kadzielski adds.
He says that means hospitals would be well-advised to establish information-sharing agreements with managed care plans and health plans in their area. "Either that, or put their heads in the sand and pretend they don’t know anything; because legally, they are not entitled to get anything."
The HIPDB dramatically expands the scope of the 10-year-old National Practitioner Data Bank (NPDB), which contains reports of medical malpractice payments, adverse licensing actions, adverse clinical privileges actions, and adverse professional society membership actions on more than 133,000 providers.
The new data bank, mandated by the Health Insurance Portability and Accountability Act of 1996, will include certain final adverse actions taken against health care providers, suppliers, and practioners including:
- civil judgments, with the exception of malpractice judgments, in federal or state courts related to the delivery of a health care item or service;
- federal or state criminal convictions related to the delivery of a health care item or service;
- actions by federal or state agencies responsible for the licensing and certification of health care providers;
- exclusion from participation in federal or state health care programs.
The HIPDB will have other ramifications as well, says Kadzielski. Unlike the NPDB, the HIPDB contains federal, state, and criminal convictions at every level including misdemeanors and infractions. That means that a misdemeanor or a no contest plea bargain that would solve a doctor’s criminal problem will now get them reported to the HIPDB where that information is accessible to health plans.
"One wonders whether this will result in a slowdown of plea bargains and more cases on health care fraud that are criminal or civil going to trial," warns Kadzielski. He says that’s what happened in 1990 when the NPDB was established. "The HIPDB is going to have the same impact."
The final rule implementing the HIPDB was published in the Federal Register Oct. 26 and took effect immediately. The data bank will begin receiving information next month and start accepting requests for reports early next year.
The final rule for the OIG’s HIPDB is available on the HHS’ Web site at www.hhs.gov. Click on "What’s New."
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