Fighting Fraud: Healthcare Integrity and Protection Data Bank

By Ronald L. Scott
Rscott@central.uh.edu

The national Healthcare Integrity and Protection Data Bank (HIPDB) was established by the Health Insurance Portability and Accountability Act of 1996. Reporting to the new data bank started November 22, 1999. The HIPDB was created to combat fraud and abuse in health insurance and health care delivery. The HIPDB contains information regarding civil judgments, criminal convictions, or actions by federal or state licensing agencies against a health care provider, supplier, or practitioner related to the delivery of a health care item or service.

There is some overlap between information contained in the HIPDB and the existing National Practitioner Data Bank (NPDB) established by the Health Care Quality Improvement Act of 1986. The NPDB was established as a central information clearinghouse to collect and release information related to the professional conduct and competence of physicians, nurses, dentists and other health care practitioners. The intent of the NPDB is to support professional peer review by encouraging hospitals, state licensing boards, professional societies, and other health care entities to identify and discipline health care practitioners who engage in unprofessional conduct. The NPDB contains information about health care practitionersí malpractice payments, adverse licensure actions, restrictions on professional membership, and negative privileging actions by hospitals.

The HIPDB also contains information relating to the exclusion of a health care provider, supplier, or practitioner from participation in federal or state health care programs. All licensing boards are required to report to both the HIPDB and the NPDB. Reports on medical malpractice payments, clinical privileges actions, and professional society membership actions will only be in the NPDB. Civil judgments and criminal convictions will only be contained in the HIPDB. The HIPDB will collect and maintain records of some licensure actions, e.g., adverse licensure actions from August 21, 1996 on must be reported to HIPDB. Access to information in the HIPDB will not be available to the public, but will be available to federal and state government agencies, health plans, and via self-query (where a practitioner accesses his own records) similar to the NPDB. A joint web site has been established for NPDB-HIPDB at http://www.npdb-hipdb.com.

Most civil judgments against health care providers related to health care are reportable to the HIPDB, with one important exception. Malpractice findings are not reportable to the HIPDB (although they remain reportable to the NPDB). Some critics of the current structure of the NPDB believe that the database should be accessible to the public. House Commerce Committee Chairman Thomas Bliley is considering introducing legislation to allow public access to the NPDB. The American Medical Association opposes such access because the physician organization does not believe malpractice information is related to competency. Although the AMA originally supported a version of the NPDB (without malpractice information), it now favors abolishing the NPDB because it contains malpractice information. See New Data Bank Focuses on Fraud at http://www.ama-assn.org/sci-pubs/amnews/pick_99/gvta1122.htm. The HIPDB will hopefully prove to be a valuable tool to combat fraud in the provision of health care.

12/10/99