Health Hippo: Professionals

Health Hippo: Professionals


Medicine is of all the Arts the most noble; but, not withstanding, owing to the ignorance of those who practice it, and of those who, inconsiderately, form a judgment of them, it is at present far behind all the other arts.

The Affordable Care Act includes federal investments in the health care
workforce designed to train new primary care providers –
including physicians, nurse practitioners and physician assistants – and
encourage primary care providers to practice in underserved areas. The
number of primary care providers in the National Health Service has more
than doubled, Community Health Centers have been funded nationwide,
primary care providers are being trained in community settings,
integrated care is being promoted for the chronically ill, and a new
“Innovation Center” is accepting, implementing and rewarding ideas that
deliver better care and lower costs to the Medicare and Medicaid

U.S. Code

  • Affordable Care Act Quality and

    • Sec. 3002. Improvements
      to the physician quality reporting system.
    • Sec. 3003. Improvements to the physician
      feedback program.
    • Sec. 3007.
      Value-based payment modifier under the physician fee schedule.
    • Sec. 3011. National strategy.
    • Sec. 3012. Interagency Working Group on Health
      Care Quality.
    • Sec. 3013. Quality
      measure development.
    • Sec. 3014. Quality
    • Sec. 3015. Data
      collection; public reporting.
    • Sec.
      Establishment of Center for Medicare and Medicaid Innovation
      within CMS.
    • Sec. 3022. Medicare shared
      savings program.
    • Sec. 3023. National
      pilot program on payment bundling.
    • Sec.
      Extension of gainsharing demonstration.
    • Sec. 3101. Increase in the physician payment
    • Sec. 3102. Extension of the
      work geographic index floor and revisions to the practice expense
      geographic adjustment under the Medicare physician fee schedule.
    • Sec. 3107. Extension of physician fee schedule
      mental health add-on.
    • Sec. 3108.
      Permitting physician assistants to order post-Hospital extended care
    • Sec. 3114. Improved access
      for certified nurse-midwife services.
    • Sec.
      Health care delivery system research; Quality improvement
      technical assistance.
    • Sec. 3508.
      Demonstration program to integrate quality improvement and patient
      safety training into clinical education of health professionals.
    • Sec. 3511. Authorization of appropriations.
    • Sec. 6001. Limitation on Medicare
      exception to the prohibition on certain physician referrals for
    • Sec. 6002. Transparency
      reports and reporting of physician ownership or investment interests.
    • Sec. 6003. Disclosure requirements for
      in-office ancillary services exception to the prohibition on physician
      self-referral for certain imaging services.
    • Sec. 6801. Sense of the Senate regarding
      medical malpractice.
    • Sec. 10310.
      Repeal of physician payment update.
    • Sec.
      Revision to community health teams.
    • Sec. 10327. Improvements to the physician
      quality reporting system.
    • Sec. 10330.
      Modernizing computer and data systems of the Centers for Medicare &
      Medicaid services to support improvements in care delivery.
    • Sec. 10331. Public reporting of performance
    • Sec. 10332. Availability
      of medicare data for performance measurement.
    • Sec. 10333. Community-based collaborative
      care networks.
    • Sec. 10908. Exclusion
      for assistance provided to participants in State student loan repayment
      programs for certain health professionals.
  • Affordable Care Act Health Care

    • Sec. 5001. Purpose.
    • Sec. 5002. Definitions.
    • Sec. 5101. National health care workforce
    • Sec. 5102. State health
      care workforce development grants.
    • Sec.
      Health care workforce assessment.
    • Sec. 5201. Federally supported student loan
    • Sec. 5202. Nursing student loan
    • Sec. 5203. Health care
      workforce loan repayment programs.
    • Sec.
      Public health workforce recruitment and retention programs.
    • Sec. 5205. Allied health workforce
      recruitment and retention programs.
    • Sec.
      Grants for State and local programs.
    • Sec. 5207. Funding for National Health Service
    • Sec. 5208. Nurse-managed health
    • Sec. 5209. Elimination of cap
      on commissioned corps.
    • Sec. 5210.
      Establishing a Ready Reserve Corps.
    • Sec.
      Training in family medicine, general internal medicine,
      general pediatrics, and physician assistantship.
    • Sec. 5302. Training opportunities for direct
      care workers.
    • Sec. 5303. Training in
      general, pediatric, and public health dentistry.
    • Sec. 5304. Alternative dental health care
      providers demonstration project.
    • Sec.
      Geriatric education and training; career awards; comprehensive
      geriatric education.
    • Sec. 5306. Mental
      and behavioral health education and training grants.
    • Sec. 5307. Cultural competency, prevention,
      and public health and individuals with disabilities training.
    • Sec. 5308. Advanced nursing education grants.
    • Sec. 5309. Nurse education, practice,
      and retention grants.
    • Sec. 5310. Loan
      repayment and scholarship program.
    • Sec.
      Nurse faculty loan program.
    • Sec.
      Authorization of appropriations for parts B through D of title
    • Sec. 5313. Grants to promote the
      community health workforce.
    • Sec. 5314.
      Fellowship training in public health.
    • Sec.
      United States Public Health Sciences Track.
    • Sec. 5401. Centers of excellence.
    • Sec. 5402. Health care professionals training
      for diversity.
    • Sec. 5403.
      Interdisciplinary, community-based linkages.
    • Sec. 5404. Workforce diversity
    • Sec. 5405. Primary care extension program.
    • Sec. 5501. Expanding access to primary
      care services and general surgery services.
    • Sec. 5502. Medicare Federally qualified health
      center improvements.
    • Sec. 5503.
      Distribution of additional residency positions.
    • Sec. 5504. Counting resident time in
      nonprovider settings.
    • Sec. 5505. Rules
      for counting resident time for didactic and scholarly activities and
      other activities.
    • Sec. 5506.
      Preservation of resident cap positions from closed hospitals.
    • Sec. 5507. Demonstration projects To address
      health professions workforce needs; extension of family-to-family health
      information centers.
    • Sec. 5508.
      Increasing teaching capacity.
    • Sec.
      Graduate nurse education demonstration.
    • Sec. 5601. Spending for Federally Qualified
      Health Centers (FQHCs).
    • Sec. 5602.
      Negotiated rulemaking for designating medically underserved populations
      and health professions shortage areas.
    • Sec.
      Reauthorization of the Wakefield Emergency Medical Services
      for Children Program.
    • Sec. 5604.
      Co-locating primary and specialty care in community-based mental health
    • Sec. 5605. Key National
    • Sec. 5701. Reports.
    • Sec. 10501. Amendments to the Public Health
      Service Act, the Social Security Act, and title V of this Act.

      • Interagency Task Force To Assess And Improve Access To Health
        Care In The State Of Alaska
      • Demonstration Grants For Family Nurse
        Practitioner Training Programs
      • National Diabetes Prevention Program
      • Grants To Providers Of Medically Underserved Populations Or Other
        Special Populations
      • Rural Physician Training Grants
      • Preventive
        Medicine And Public Health Training Grant Program
    • Sec. 10502. Infrastructure to Expand Access
      to Care.
    • Sec. 10503. Community Health
      Centers and the National Health Service Corps Fund.
    • Sec. 10504. Demonstration project to provide
      access to affordable care.
    • Sec.
      Certain other providers permitted to conduct face to face
      encounter for home health services.
    • Sec.
      Exclusion for assistance provided to participants in State
      student loan repayment programs for certain health professionals.
  • Balanced Budget Act Health

    • Sec. 4501
      Establishment of single conversion factor for 1998.
    • Sec. 4502 Establishing update to
      conversion factor to match spending under sustainable growth rate.
    • Sec. 4503 Replacement of volume
      performance standard with sustainable growth rate.
    • Sec. 4504 Payment rules for anesthesia
    • Sec. 4505
      Implementation of resource-based methodologies.
    • Sec. 4506 Dissemination of information
      on high per discharge relative values for in-hospital physicians’
    • Sec. 4507 Use of
      private contracts by medicare beneficiaries.
    • Sec. 4511 Increased medicare
      reimbursement for nurse practitioners and clinical nurse specialists.
    • Sec. 4512 Increased medicare
      reimbursement for physician assistants.
    • Sec. 4513 No x-ray required for
      chiropractic services.
    • Sec.
      Indirect graduate medical education payments.
    • Sec. 4622 Payment to hospitals of
      indirect medical education costs for Medicare+Choice enrollees.
    • Sec. 4623 Limitation on number of
      residents and rolling average FTE count.
    • Sec. 4624 Payments to hospitals for
      direct costs of graduate medical education of Medicare+Choice enrollees.
    • Sec. 4625 Permitting payment
      to nonhospital providers.
    • Sec.
      Incentive payments under plans for voluntary reduction in
      number of residents.
    • Sec. 4627
      Medicare special reimbursement rule for primary care combined residency
    • Sec. 4628
      Demonstration project on use of consortia.
    • Sec. 4629 Recommendations on
      long-term policies regarding teaching hospitals and graduate medical
    • Sec. 4630 Study of
      hospital overhead and supervisory physician components of direct medical
      education costs.

Code of Federal Regulations

  • 32 CFR Sec. 199.15 Peer Review
    Organization Program.

  • 42 CFR
    PART 456

      General Provisions (456.1 – 456.6)
      Utilization Control: All Medicaid Services (456.21 – 456.23)
      Utilization Control: Hospitals (456.50 – 456.145)
      Utilization Control: Mental Hospitals (456.150 – 456.245)
    • SUBPART E [Reserved]
      Utilization Control: Intermediate Care Facilities (456.350 –
      Inpatient Psychiatric Services for Individuals Under Age 21:
      Admission and Plan of Care Requirements (456.480 – 456.482)
      Utilization Review Plans: FFP, Waivers, and Variances for
      Hospitals and Mental Hospitals (456.500 – 456.525)
      Inspections of Care in Intermediate Care Facilities and
      Institutions for Mental Diseases (456.600 – 456.614)
      Penalty for Failure To Make a Satisfactory Showing of an Effective
      Institutional Utilization Control Program (456.650 – 456.657)
      Drug Use Review (DUR) Program and Electronic Claims Management
      System for Outpatient Drug Claims (456.700 – 456.725)
  • 45 CFR PART

    • Sec.
      The National Practitioner Data Bank.

    • Sec. 60.2
      Applicability of these regulations.

    • Sec. 60.3

    • Sec. 60.4
      How information must be reported.

    • Sec. 60.5
      When information must be reported.

    • Sec. 60.6
      Reporting errors, omissions, and revisions.

    • Sec. 60.7
      Reporting medical malpractice payments.

    • Sec. 60.8
      Reporting licensure actions taken by Boards of Medical Examiners.

    • Sec. 60.9
      Reporting adverse actions on clinical privileges.

    • Sec.
      Information which hospitals must request

    • Sec.
      Requesting information from the National Practitioner Data
      Bank .

    • Sec.
      Information which hospitals must request from the National
      Practitioner Data Bank.

    • Sec.
      Requesting information from the National Practitioner Data

    • Sec.
      Fees applicable to requests for information.

    • Sec.
      Confidentiality of National Practitioner Data Bank

    • Sec.
      How to dispute the accuracy of National Practitioner Data Bank

Case Law


  • Improper
    Payments for Evaluation and Management Services Cost Medicare Billions
    in 2010
    (OIG 2014) In total, Medicare inappropriately paid $6.7
    billion for claims for E/M services in 2010 that were incorrectly coded
    and/or lacking documentation, representing 21 percent of Medicare
    payments for E/M services that year. We found that 42 percent of claims
    for E/M services in 2010 were incorrectly coded, which included both
    upcoding and downcoding. podcast

  • Uniformed Services University of the Health Sciences
    Recent Federal Register notices.

  • Medicare: Nurse
    Anesthetists Billed for Few Chronic Pain Procedures
    (GAO 2014) Of
    all CRNA claims for selected procedures, the share billed by CRNAs in
    rural areas fell from 66 percent in 2009 to 39 percent in 2012. Chronic
    pain costs the nation about $600 billion each year, a quarter of which
    is borne by Medicare. One MAC, Noridian Healthcare Solutions (Noridian),
    began denying CRNA claims for certain chronic pain services in 2011,
    citing patient safety concerns. CMS issued a rule, effective January
    2013, clarifying that CRNAs can bill Medicare for “any services that a
    [CRNA] is legally authorized to perform in the state in which the
    services are furnished,” including chronic pain management services.

  • Public Comment on the Release of Medicare Physician Data
    (CMS 2013)
    CMS sought input regarding: (1) whether physicians have a privacy
    interest in information concerning payments they receive from Medicare,
    and if so, how to properly weigh the balance between that privacy
    interest and public interest in disclosure of Medicare payment
    information; (2) what specific policies CMS should consider with respect
    to disclosure of individual physician payment data; and (3) the form
    that should be taken for any data release.

  • Medicare Provider Utilization and Payment Data: Physician
    and Other Supplier
    (CMS 2013) The Physician and Other Supplier PUF
    contains information on utilization, payment (allowed amount and
    Medicare payment), and submitted charges organized by National Provider
    Identifier (NPI), Healthcare Common Procedure Coding System (HCPCS)
    code, and place of service.

  • MedPac: Physician and Other
    Health Professionals Payment System
    (2014) Physician services
    include office visits, surgical procedures, and a broad range of other
    diagnostic and therapeutic services. These services are furnished in all
    settings, including physicians’ offices, hospitals, ambulatory surgical
    centers, skilled nursing facilities and other post-acute care settings,
    hospices, outpatient dialysis facilities, clinical laboratories, and
    beneficiaries’ homes. Among the 1 million clinicians in Medicare’s
    registry, approximately half are physicians who actively bill Medicare.
    The remainder includes health professionals such as nurse practitioners,
    physician assistants, and physical therapists.

  • MedPac: Site Visits to Selected
    Institutions With Innovations In Residency Training
    (2010) Although
    approaches differed, several innovation foci emerged from our site
    visits, including: transforming practices into Patient-Centered Medical
    Homes (PCMHs); developing IT resources; working in multidisciplinary
    teams; improving patient-provider continuity; separating inpatient and
    outpatient clinical activities; working in community-based settings;
    implementing curricula for teaching quality improvement methods and
    delivering high-quality chronic disease care; exposing residents to
    community issues and community-based resources; working in systems
    encouraging high- performance and efficiency; and redesigning inpatient
    teaching units.

  • Improvements
    Are Needed To Ensure Provider Enumeration and Medicare Enrollment Data
    Are Accurate, Complete, and Consistent
    (OIG 2013) Inaccurate,
    incomplete, and inconsistent provider data coupled with insufficient
    oversight place the integrity of the Medicare program at risk and
    present vulnerabilities in all health care programs. CMS should require
    Medicare Administrative Contractors to implement program integrity
    safeguards for Medicare provider enrollment as established in the
    Program Integrity Manual.

  • Lack
    of Data Regarding Physicians Opting Out of Medicare
    (OIG 2012)
    Although the percentage of physicians who choose to opt out may be small
    (perhaps less than 1 percent1), monitoring the number of opted-out
    physicians and their specialties is important to ensure that Medicare
    beneficiaries have sufficient access to providers, including specialized

  • CMS
    Reporting to the Healthcare Integrity and Protection Data Bank
    2012) The Healthcare Integrity and Protection Data Bank (HIPDB) is a
    national data bank containing reports of adverse actions against health
    care practitioners, providers, and suppliers (collectively referred to
    as providers). Complete and accurate HIPDB information helps prevent the
    employment of potentially fraudulent or abusive providers.

  • Health
    Education Assistance Loan Defaulters With Income in Fiscal Year 2008

    (OIG 2010) Based on wages identified through SIDI, 486 of the 1,065 HEAL
    defaulters earned income in FY 2008. The remaining 579 defaulters did
    not have income information identified in SIDI. Of the 486 defaulters,
    312 made no loan payments during that time. These 312 HEAL defaulters
    owed $47.5 million on their loans and earned $13.4 million in FY 2008.

  • Foreign
    Physicians: Data on Use of J-1 Visa Waivers Needed to Better Address
    Physician Shortages
    (GAO 2006) More than 1,000 waivers were
    requested in each of fiscal years 2003 through 2005 by states and three
    federal agencies–the Appalachian Regional Commission, the Delta
    Regional Authority, and HHS. At the end of fiscal year 2005, the
    estimated number of physicians practicing in underserved areas through
    J-1 visa waivers exceeded the number practicing there through the
    National Health Service Corps (NHSC)–HHS’s primary mechanism for
    addressing physician shortages.

  • HHS
    Agencies ComplianceWith the National Practitioner Data Bank Malpractice
    Reporting Policy
    (OIG 2005) We found that, as of October 2004, HHS
    agencies failed to report as many as 474 medical malpractice cases to
    the NPDB that should have been reported.

  • Managed Care
    Organization Nonreporting to the National Practitioner Data Bank: A
    Signal for Broader Concern
    (OIG 2001) With close to 100 million
    individuals enrolled in these organizations and hundreds of thousands of
    physicians and dentists associated with them, fewer than 1,000 adverse
    action reports over nearly a decade serves for all practical purposes as

  • Foreign
    Physicians: Exchange Visitor Program Becoming Major Route to Practicing
    in U.S. Underserved Areas
    (GAO 1996) GAO reviewed the extent to
    which state and federal agencies used waivers to meet physician
    shortages in medically underserved areas, focusing on: (1) how many
    foreign physicians with J-1 visas receive waivers, where they practice,
    and their medical specialties; (2) whether federal agencies and states
    effectively coordinate policies and procedures for granting these
    waivers; and (3) the extent to which foreign physicians who receive
    waivers comply with waiver requirements to practice in underserved

  • Insurance:
    Profitability of the Medical Malpractice and General Liability Lines

    (GAO 1997) Medical malpractice line incurred losses when the reserves
    were valued at their full estimated payout, but was profitable when the
    reserves were discounted to present values.

  • Medical Malpractice: Federal Tort Claims Act
    Coverage Could Reduce Health Centers’ Costs
    (GAO 1997) Pursuant to a
    legislative requirement, GAO reviewed the implementation of Federal Tort
    Claims Act (FTCA) coverage for community health centers.

  • Medicare: Private-Sector and Federal Efforts to
    Assess Health Care Quality
    (GAO 1996) GAO discussed the Health Care
    Financing Administration’s (HCFA) efforts to provide health care quality
    information to Medicare beneficiaries joining health maintenance

  • Practice
    Guidelines: Managed Care Plans Customize Guidelines to Meet Local
    (GAO 1996) Pursuant to a congressional request, GAO
    reviewed how managed health plans make use of existing clinical practice

  • Medicare: Federal Efforts to Enhance Patient
    Quality of Care
    (GAO 1996) Pursuant to a congressional request, GAO
    reviewed the Health Care Financing Administration’s (HCFA) efforts to
    enhance the quality of care for Medicare beneficiaries.

  • Medicare:
    Millions Can Be Saved by Screening Claims for Overused Services
    1996) GAO provided information on Medicare payments for unnecessary
    medical services.

  • Medical
    Liability: Impact on Hospital and Physician Costs Extends Beyond
    (GAO 1995) GAO reviewed the types of medical liability
    costs that affect hospitals and physicians, and whether existing studies
    include these costs in their estimates of hospital and physician
    liability expenses.

  • Practice
    Guidelines: Overview of Agency for Health Care Policy and Research
    (GAO 1995) In 1989, Congress created the Agency for Health
    Care Policy and Research–part of the Public Health Service–to serve as
    the federal government’s focal point for effectiveness and outcomes

  • Medicare: Graduate Medical Education Payment Policy
    Needs to Be Reexamined
    (GAO 1994) It is widely held that the United
    States is not training enough primary care physicians relative to other
    types of physicians.

  • Medical
    Education: Curriculum and Financing Strategies Need to Encourage Primary
    Care Training
    (GAO 1994) The proportion of active doctors who are
    primary care physicians–family and general practice physicians, general
    internists, and pediatricians–has dropped from 53 to 35 since 1960.

  • Primary Care Physicians: Managing Supply in
    Canada, Germany, Sweden, and the United Kingdom
    (GAO 1994) GAO
    examined the methods used by four nations–Canada, Germany, Sweden, and
    the United Kingdom–to manage their physician supply and specialty

  • Medical
    Malpractice: Maine’s Use of Practice Guidelines to Reduce Costs
    1993) As part of a larger goal of reducing health care costs and
    improving medical care, Maine is testing an innovative medical
    malpractice reform initiative.

  • Practice
    Guidelines: The Experience of Medical Specialty Societies
    (GAO 1991)
    GAO also found that it was unable to make any recommendations on
    guideline development because of the: (1) variability in guideline
    development in the past and in the opinions about how it should proceed
    in the future; and (2) absence of evaluative studies on guideline
    development and guideline impacts.

  • Use of
    Medicare Offset Agreements and Exclusions for National Health Service
    Corps and Health Education Assistance Loan Defaulters
    (OIG 1991)
    Medicare offset and exclusion procedures are not being employed against
    defaulters in the Deparment of Health and Human Services’ scholarship
    and loan programs for students in the heathprofessions. To date, the
    Public Heath Service (PHS), which is responsible for debt management
    activities, has not yet implemented the offset procedure, and has
    initiated the exclusion option against only one National Heath Service
    Corps (NHSC) scholarship defaulter.

  • Health
    Education Assistance Loan (HEAL)
    (OIG 1991) This study was initiated
    because of high-level concerns about financial problems the HEAL program
    has been experiencing due to an increasing default rate. The Public
    Health Service (PHS) projects the Student Loan Insurance Fund (SLIP) wil
    not have suffcient funds to pay the increasing number of claims.

  • Health
    Education Assistance Loan Program
    (OIG 1985) In case of default ,
    death, disability or bankruptcy, the holder of the loan is reimbursed
    the full amount of principal and accrued interest from the Student Loan
    Insurance Fund (SLIF). Deposits to the fund are derived from insurance
    premiums (currently 2 percent) deducted from the loan principal at the
    time of award.

  • Coding
    Trends of Medicare Evaluation and Management Services
    (OIG 2012)
    Medicare payments for evaluation and management (E/M) services increased
    by 48 percent, from $22.7 billion to $33.5 billion. E/M services have
    been vulnerable to fraud and abuse. In 2009, two health care entities
    paid over $10 million to settle allegations that they fraudulently
    billed Medicare for E/M services. The Centers for Medicare & Medicaid
    Services (CMS) also found that certain types of E/M services had the
    most improper payments of all Medicare Part B service types in 2008.

  • South
    Florida Medicare Comprehensive Outpatient Rehabilitation Facilities

    (OIG 2011) CORFs provide multidisciplinary outpatient rehabilitation
    services at a single location. Medicare allowed approximately $70
    million for almost 40,000 beneficiaries nationwide who received CORF
    services in 2010. Of this amount, more than $22 million was for claims
    by South Florida CORFs. In 2010, more than 25 percent of all CORFs were
    in South Florida.

  • Medicaid
    Services Provided in an Adult Day Health Setting
    (OIG 2011) On many
    service days, beneficiaries’ only documented services were meals and/or
    snacks. Many also received therapy services from staff who were not
    supervised in accordance with State requirements. Our findings indicate
    the need for (1) explicit requirements regarding the provision of health
    services in Medicaid adult day health centers and (2) enforcement of
    current therapy supervision requirements.

  • Inappropriate
    Claims for Medicaid Personal Care Services
    (OIG 2010) PCS attendants
    provide the elderly and people with disabilities with the assistance
    they need to remain in their homes and communities. Combined State and
    Federal Medicaid expenditures for PCS totaled $9.9 billion in 2006, an
    increase of 20 percent since 2004.

  • Prevalence
    and Qualifications of Nonphysicians Who Performed Medicare Physician
    (OIG 2009) Medicare Part B pays for services that are
    billed by physicians but are performed by nonphysicians. These services
    often are called “incident to” services, or services provided under the
    “incident to” rule. “Incident to” services may be vulnerable to
    overutilization and may put beneficiaries at risk of receiving services
    that do not meet professionally recognized standards of care.

  • Medicare
    Payment for Nonphysician Clinical Staff in Cardiothoracic Surgery

    (OIG 2002) This inspection assesses the frequency, payment, and reasons
    cardiothoracic surgeons use their own nonphysician clinical staff to
    perform surgery-related hospital duties and the manner and extent to
    which Medicare pays for these services.

  • Medicare
    Coverage of Non-Physician Practitioner Services
    (OIG 2001) To
    describe the scope of services nurse practitioners, clinical nurse
    specialists, and physician assistants provide to Medicare beneficiaries,
    and to identify any potential vulnerabilities that may have emerged
    since the Balanced Budget Act of 1997.

  • Nonprofessional Services in Skilled Nursing Facilities
    (OIG 1995)
    This report examines the extent of Part B billings for nonprofessional
    institutional services such as enteral nutrition services, incontinence
    care services, and surgical dressings provided to beneficiaries during
    Medicare covered SNF stays. We did not review situations where an
    individual in a SNF was not covered by Part A but receiving a SNF level
    of care.

  • Carriers
    Still Need to Purge Unused Provider Numbers
    (OIG 1995) In a May 1991
    report the Office of Inspector General (OIG) found that most carriers
    did not systematically update provider files. The OIG found that
    carriers could reduce Medicare’s vulnerability to abuse and save
    administrative costs by periodically deactivating provider numbers with
    no billing history.

  • National
    Practitioner Data Bank Reports to Hospitals: Their Usefulness and
    (OIG 1995) Hospital officials are receiving reports in a much
    more timely fashion and they are now much more likely to characterize
    Data Bank information as useful. At the same time, our data reveal that
    Data Bank reports seldom affect privileging decisions of hospitals.

  • National
    Practitioner Data Bank Reports to Managed Care Organizations: Their
    Usefulness and Impact
    (OIG 1995) Almost all–96 percent–managed
    care organizations receiving information from the Data Bank find it
    usefid. In fact, this percent is considerably higher than the percent of
    hospitals finding the information useful (83 percent). At the same time,
    our data reveal that Data Bank reports seldom affect privileging
    decisions of managed care organizations.

  • Hospital
    Reporting to the National Practitioner Data Bank
    (OIG 1995) Our
    review suggests a sufficient basis for concern about the hospitals’
    response to the Data Bank reporting requirements. The wide variation in
    reporting rates from State to State is in itself troubling. It could
    suggest differences in the quality of care rendered or perhaps in the
    capacity or willingness of hospitals to submit reports to the Data Bank.

  • National
    Practitioner Data Bank: Profile of Matches Update
    (OIG 1995) When a
    request names a practitioner who has been reported to the Data Bank, the
    request-report pair is referred to as a “match.” As a result of the
    queries made by April 1994, 152,941 matches had occurred.

  • Enhancing the
    Utilization of Nonphysician Health Care Providers
    (OIG 1993) This
    report focuses on making the delivery of health care more productive by
    using nonphysician providers differently. It is not a formal evaluation
    of the success or failure of health care organizations in reaching this
    goal. Rather, the report identifies and describes approaches that some
    organizations are taking to make better use of such personnel. We also
    describe fundamental barriers that inhibit the broader use of such

  • Enhancing the
    Utilization of Nonphysician Health Care Providers: Three Case
    (OIG 1993) Evercare, a managed care delivery system in
    Minneapolis illustrates how nurse practitioners working in collaboration
    with physicians can enhance the delivery of care to nursing home
    residents. St. Joseph’s Hospital of Atlanta is using professional and
    nonprofessional hospital staff on two units to dliver more patient care
    services directly at the bedside. Chicago’s Mercy Hospital and Medical
    Center is training nonprofessional workers to perform technical tasks
    and to work in permanent teams with registered nurses in a hospital-wide
    expansion of the hospital’s nursing service.

  • National
    Practitioner Data Bank: Usefulness and Impact of Reports to State
    Licensing Boards
    (OIG 1993) Most licensing boards have not queried
    the Data Bank. Among their reasons for not querying is that they already
    receive much of the information sent to the Data Bank. Our results
    suggest, however, that boards may be underestimating the value of
    querying the Data Bank.

  • National
    Practitioner Data Bank: Usefulness and Impact of Reports to
    (OIG 1993) Our findings indicate that the usefulness and
    impact of the information in the Data Bank are strongly affected by the
    timeliness of the reports. Our recommendations identify steps that PHS
    and hospitals need to take to improve the timeliness of Data Bank
    reports, since PHS shares the responsibility for timeliness with the
    hospitals that query the Data Bank.

  • State
    Dental Boards and Dental Discipline
    (OIG 1993) The information
    presented in this report reinforces the concerns of many State dental
    board officials about the capacity of the boards to carry out their
    disciplinary responsibilities. But the significance of the information
    goes beyond whether or not out-of-State dentists should be licensed by
    any given board. It suggests that many boards may not be providing
    adequate protection to consumers.

  • Carrier
    Assignment of Medicare Provider Numbers
    (OIG 1992) Medicare carriers
    assign provider numbers to qualified providers of Part B services who
    furnish services or supplies to Medicare beneficiaries. The numbers are
    used in processing claims and establishing Medicare pricing and
    utilization profiles. To obtain a provider number from a carrier,
    providers typically complete the carrier’s provider number application
    form and meet criteria specified by Medicare regulations.

  • National
    Practitioner Data Bank–Unauthorized Access by Ineligible Health Care
    (OIG 1992) Representatives of the Data Bank Executive
    Committee as well as the media have raised concerns about the Data Bank
    information being provided to ineligible health care entities.

  • National
    Practitioner Data Bank: Malpractice Reporting Requirements
    1992) Because our inspection was limited in scope, we cannot offer a
    definitive recommendation as to whether or not to change the Data Bank
    reporting requirements. Additional information, such as the predictive
    value of open claims and small payments and the overall distribution of
    malpractice payment amounts, is needed to make such an assessment.

  • National
    Practitioner Data Bank: Profile of Matches
    (OIG 1992) When a
    hospital, licensing board, or other health care entity requests
    information on a certain practitioner from the Data Bank, and that
    practitioner has been reported to the Data Bank, the query-record pair
    is referred to as a “match.”

  • Carrier
    Maintenance of Medicare Provider Numbers
    (OIG 1991) If the provider
    of services does not have a provider number, payment may not be made for
    services. To obtain a provider number from a carrier, providers need to
    complete the carrier’s application form and met criteria specified by
    Medicare mgulations.

  • National
    Practitioner Data Bank–Use of Authorized Agents
    (OIG 1990) We
    recommended that PHS implement policies to assure that authorized agents
    are reputable and that such agents utile appropriate security measures
    to assure the confidentiality of Data Bank information. We also
    recommended that Data Bank forms be modified to describe the
    confidentiality requirement.


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