/. 
""'CE 
DEPARTMENT OF HEALTH &. HUMAN SERVICES	 Office of Inspector General 
.("-"'''.0	 Washington , D. C. 20201 
2005 
OCT  1 1 
TO:	 Betty James Duke

Administrator

Health Resources and Services Administration

Elias Zerhoumi, M. 
Director 
National Institutes of Health 
Charles Grim, D.  , M.

Director

Indian Health Service

FROM: 
Daniel R. Levinson 

Inspector General 
HHS Agencies' Compliance With the National Practitioner Data Bank 
SUBJECT: 
Malpractice Reporting Policy, OEI-12-04-0031O 
Attached for your review is our final report examining Department of Health and Human 
Services (HHS) agencies ' compliance with the medical malpractice reporting 
requirements of the National Practitioner Data Bank (NDB). The NPDB, which is 
managed by the Health Resources and Services Administration (HRSA), receives and 
maintains records of medical malpractice payments and of adverse actions taken by 
hospitals, other health care entities, licensure boards, and professional societies against 
licensed health care practitioners. The NPDB makes these reports available to hospitals 
other health care entities, and licensure boards to facilitate their background checks and 
credentialing. 
According to an October 15, 1990, HHS policy directive, all settled or adjudicated HHS 
medical malpractice cases must be reported to the NPDB. This policy applies to all cases 
regardless of whether the standard of care has been met. The only exception is for those 
cases in which the adverse event was caused by system error. 
We reviewed lists that HHS' s Program Support Center (PSC) maintains of all HHS 
medical malpractice cases that have been settled or adjudicated. We focused on the 
period June 1997 through September 2004. 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. Individual agency 
underreporting was as follows: Indian 
Health Service (IHS), 290 cases; HRSA, 179 cases; and National Institutes of Health 
(NIH), 5 cases.  This departmentwide underreporting was caused by a number of factors including: 
(1) lost medical malpractice files; (2) incomplete information in medical malpractice 
1998 decision by the HHS peer review entity, the Medical Claims Review 
fies; (3) a 
Panel, to not identify practitioners who met the standard of care (a decision that was 
inconsistent with longstanding HHS policy); and (4) the failure to replace a key PSC 
claims official or to reassign his NPDB reporting duties. 
Failure to report medical malpractice cases to the NPDB has the effect of depriving 
health care organizations, such as hospitals and State licensure boards, of potentially 
useful information for their credentialing and regulatory activities, respectively. 
We recommend that IHS , HRSA, and NIH each take steps to: (1) implement a corrective 
action process that would address the uneported cases, (2) improve internal controls 
involving case fies management, and (3) assign staff to assume responsibility for 
addressing practitioner questions/complaints and data entry of reports to the NPDB. 
In reply to the draft report, we received a response from the HRSA Administrator, who 
responded on behalf of the Secretary. This response, which is attached at Appendix A to 
this report, indicated that the Department is working to develop a final action plan that 
wil include policy decisions relating to future reporting, including ensuring agency 
compliance. The response also included agency techncal comments from HRSA, NIH 
and IHS , which we have addressed as appropriate, in the attached report. 
Since April 22, 2005 , in response to the OIG review, IHS has reported 99 providers. 
However, contrary to current HHS policy, IHS is not reporting cases in which the 
standard of care was met. 
Prior to the April 2005 IHS reporting, the last time HHS agency cases were entered into 
the NPDB was in July 2003 (two HRSA cases). NPDB staff have advised OIG that, as of 
June 30, 2005 , neither HRSA nor NIH have reported any cases. 
Please send us your final management decision, including any action plan, as appropriate 
within 60 days. If you have any questions or comments about this report, please do not 
hesitate to call me or one of your staff may contact Elise Stein, Director, Public Health 
and Human Services Branch, at (202) 619-2686 or through e-mail 
Elise.Stein  oig.hhs.gov). To facilitate identification, please refer to report number 
OEI-12-04-00310 in all correspondence. 
cc: 
Paula Stannard 
Acting General Counsel 
Department of Health and Human Services 
Ann Agnew 
Executive Secretary to the Department of Health and Human Services  HHS AGENCIES COMPLIANCE WITH THE NATIONAL 

PRACTITIONER DATA BANK MALPRACTICE REPORTING 

POLICY, OEI-12-04-00310 

BACKGROUND 
National Practitioner Data Bank 
The Health Care Quality Improvement Act of 1986 (the Act), as amended,1 created the 
National Practitioner Data Bank (NPDB).  Since it became operational in September 
1990, the NPDB has received and maintained records of medical malpractice payments 
and of adverse actions taken by hospitals, other health care entities, licensure boards, and 
professional societies against licensed health care practitioners.  The NPDB makes these 
reports available to hospitals, other health care entities, and licensure boards to facilitate 
their background checks and credentialing. 
At the end of September 2004, the NPDB contained 358,590 reports on individuals, of 
which 263,742 were medical malpractice payment reports.  During the first 9 months of 
2004, the NPDB received 2,652,153 requests for information from hospitals, other health 
care entities, and licensure boards.  Of those requests, 371,565 matched information 
contained in the NPDB, for a match rate of 14 percent.  The NPDB also received 
37,879 self-queries from practitioners.  Of these self-query requests, 2,300 matched 
reports in the NPDB, for a self-query match rate of 11 percent.  A HRSA-funded survey 
of NPDB users in 2000 by the University of Illinois and Northwestern University found 
that 9 percent of the time an NPDB report caused the hospital, other health care entity, or 
licensure board to change a privileging, membership, or licensing decision.  Based on the 
survey results, HRSA has estimated that, for a 1-year period, 40,100 licensure, 
credentialing, or membership decisions were affected by new information provided in 
NPDB responses. 
Section 421 of the Act2 requires that private insurers and self-insured health care entities 
report medical malpractice settlements or court judgments to the NPDB.  However, the 
statute does not explicitly require HHS or other Federal departments to report medical 
malpractice settlements or court judgments.  Instead, section 4323 requires that HHS enter 
into Memorandums of Agreement with the Department of Defense (DOD) and 
Department of Veterans Affairs (VA) regarding their reporting policies.  These 
agreements, dated November 1990 and September 1997, respectively, outline DOD and 
1 Title IV of P.L. 99-660, 100 Stat. 3784 (codified at 42 U.S.C.  11101-11152). 

2 42 U.S.C.  11131. 

3 42 U.S.C.  11152. 

OEI-12-04-00310   HHS Agencies Compliance With the National Practitioner Data Bank Malpractice Reporting Policy  VA reporting practices. In May 2004 DOD issued Instruction 6025.13, which updated 
and modified its reporting procedures.  VAs updated reporting procedures are found at 38 
CFR Part 46. 
HHS set forth its own policy on agency medical malpractice reporting in an October 15, 
1990, directive from the Assistant Secretary for Health to Public Health Service (PHS) 
agency heads.  This policy statement is entitled Policies for PHS Reporting and Querying 
the National Practitioner Data Bank.  The policy memorandum states that reports are to 
be made whenever payment is made as a result of a claim or suit filed against the U.S. 
Government alleging substandard practice by a physician, dentist, or other health care 
practitioner providing services under the auspices of PHS or one of its programs.  The 
policy provides that if a payment results from a claim in which it was determined that the 
standard of care was met, the payment . . . shall be reported under the name of the 
physician(s), dentist(s), or other licensed health care practitioner(s) found through the 
procedures to be primarily responsible for the episode . . . .  The policy also states that 
the finding that the standard was met will be clearly indicated under any names so 
reported. An exception to this reporting requirement is for payments for claims 
determined to be the result of a system breakdown, rather than the fault of the provider. 
The October 15, 1990, directive also requires that HHS, at the time a report is made to the 
NPDB, . . . send a copy to the State Board of Medical or Dental Examiners in the State in 
which the claim arose and to the State(s) of known licensure of the responsible 
practitioner within 30 days from the date . . . payment was made . . . .  This HHS policy 
reflects a similar requirement set forth in section 424 of the Act,4 which mandates private- 
sector medical malpractice reporting to State licensing boards at the time such reports are 
made to the NPDB.    
In October 1995, PHS was reorganized.  The November 9, 1995, Federal Register Notice 
(60 FR 56605) announced the elimination of the Office of the Assistant Secretary of 
Health and the designation of PHS agencies, which had been organizationally part of the 
Office of the Assistant Secretary of Health, as Operating Divisions reporting directly to 
the Secretary.  Although the Office of the Assistant Secretary of Health no longer existed 
as an organizational entity, the PHS policy on medical malpractice reporting to the NPDB 
remained in effect.  The Federal Register announcement noted as follows:  . . . all 
statements of policy and interpretations with respect to the Office of the Secretary, and the 
Public Health Service heretofore issued and in effect prior to the date of the reorganization 
are continued in full force and effect . . . . 
4 42 U.S.C.  11134. 
OEI-12-04-00310  HHS Agencies Compliance With the National Practitioner Data Bank Malpractice Reporting Policy 
2  The Federal Tort Claims Act and the Processing of Medical Malpractice Claims 
Within HHS 
The Federal Tort Claims Act (FTCA)5 is a limited waiver of Federal sovereign immunity 
under which, with certain exceptions, the United States may be liable for the negligent 
conduct of its employees acting within the scope of their employment to the same extent  
a private party would be liable under the governing State law.  Claims under the FTCA 
may include medical malpractice claims.  Under the FTCA, claimants must first present 
an administrative claim for agency consideration and possible administrative settlement.  
If the agency denies the claim or more than 6 months elapse after presentation without 
agency disposition, the claimant may deem the claim denied and file suit against the 
United States in Federal district court.  
The Program Support Centers (PSC) Claims Office is responsible for the administrative 
processing of all Federal tort claims involving medical malpractice against practitioners 
employed by HRSA, IHS, and NIH.6  PSCs Claims Office staff collect medical records 
and other information related to the plaintiffs claim and then forward the file to peer 
reviewers at the agency where the practitioner works.  Agency peer review staff, or a 
medical review contractor working for the agency, evaluate the merits of the claim and 
make an initial determination as to whether the standard of care was met or not met.  The 
case file then goes to the Office of the General Counsel (OGC) for a determination of 
whether to deny the claim or settle.  Once a claim has been paid pursuant to a settlement 
or court judgment, OGC sends the cases to the HHS Medical Claims Review Panel, Office 
of the Secretary. The Medical Claims Review Panel is a peer review group that includes 
medical staff from the Health Resources and Services Administration (HRSA), Indian 
Health Service (IHS), National Institutes of Health (NIH), and other HHS agencies.  The 
Medical Claims Review Panel is responsible for:  (1) making a final determination as to 
whether the standard of care was met or not met, and (2) identifying the clinician(s) who 
provided the treatment giving rise to the claim.  The named practitioner(s) will then be 
reported to the NPDB.7 
Once the Medical Claims Review Panel completes its review, the case is sent back to PSC 
for reporting to the NPDB.  All medical malpractice reports to the NPDB must contain the 
5 P. L. 109-41 
6 The PSC Claims Office staff handling this responsibility were transferred to OGC in October 2004, after 
the period covered by this study.  For purposes of describing the step-by-step process of the handling of 
medical malpractice cases, we are using the organizational framework that existed at the time of the study. 
7 Prior to 2004, almost all claims were reviewed by the Medical Claims Review Panel prior to settlement or 
litigation to provide additional peer review input to OGC attorneys handling the claims.  Starting in 2004, 
the reviews have been done after the claim was settled or adjudicated.  The change was made to expedite the 
processing of cases within HHS. 
OEI-12-04-00310  HHS Agencies Compliance With the National Practitioner Data Bank Malpractice Reporting Policy 
3  name and signature of an agency official who certifies that the report is accurate.  In 
addition, all reports to the NPDB must contain the name of the reporting entity and the 
name of a contact person a practitioner named in a report could call to discuss the report.  
All practitioners who are reported to the NPDB automatically receive a copy of the report.  
At the time PSC submits a report to the NPDB, a copy of the report is also forwarded to 
the appropriate State licensure board. 
According to PHS policy, once a case is settled or adjudicated, a report is supposed to be 
made to the NPDB within 30 days.   
METHODOLOGY 
Our work took place from November 2003 through March 2005. 
We reviewed lists of all HHS medical malpractice cases that have been settled or 
adjudicated that the PSC Claims Office maintained; we focused on the period June 1997 
through September 2004.  These listings provide historical information, by HHS agency, 
for the following data elements:  case number, claimant, dollar amount of settlement or 
judgment, provider name, standard of care met/not met, date PSC requested verification of 
information to be reported to the NPDB, and date reported to the NPDB.  To obtain a 
better understanding of the processes HHS agencies use for reporting to the NPDB, we 
held discussions with knowledgeable staff from HRSA, IHS, NIH, PSC, and OGC.  We 
also talked with a representative of the Federation of State Medical Licensing Boards 
(FSMB).  When necessary, we used e-mail to obtain additional or clarifying information 
from individuals. 
We conducted this study in accordance with the Quality Standards for Inspections issued 
by the Presidents Council on Integrity and Efficiency. 
FINDINGS 
Numerous HHS Cases Are Not Being Reported to the NPDB and State Licensure 
Boards 
Since the NPDB became operational in September 1990, HHS agencies have reported 257 
medical malpractice cases to the NPDB, according to HRSAs Practitioner Data Bank 
Branch, Bureau of Health Professions.  However, as a result of our review of the PSC 
listing of medical malpractice cases, the Office of Inspector General (OIG) has determined 
that as many as 474 additional cases should have been reported to the NPDB but were not.  
These unreported cases cover the period June 1997 through September 2004.  Our review 
of the PSC listing revealed the following: 
OEI-12-04-00310  HHS Agencies Compliance With the National Practitioner Data Bank Malpractice Reporting Policy 
4    290 IHS cases have not been reported, 
  179 HRSA cases have not been reported, and 
  5 NIH cases have not been reported. 
As noted earlier, PHS policy requires that all medical malpractice settlements/judgments 
be reported, except when HHS peer review determines that there was a system 
breakdown.  Of the 474 unreported cases, HHSs own peer review determined that the 
standard of care was not met in 226 IHS cases, 100 HRSA cases , and 1 NIH case.  
Furthermore, in accordance with PHS policy, even those agency cases involving 
determinations that the standard of care was met should have been reported.  While we did 
not review individual cases to identify any claims that fell into the category of system 
breakdown and, therefore, would not have to be reported, PSC has advised us that none of 
the cases included in our computations for this report involved a peer review 
determination of system breakdown.  Furthermore, we specifically excluded from our 
computations 28 HRSA cases and 10 IHS cases on the PSC listing that did not have a 
final Medical Claims Review Panel determination as to whether the standard of care was 
met or not met.  Six of these cases dated as far back as 1998/1999. 
Underreporting of the Departments own medical malpractice cases lessens the usefulness 
of the NPDB and undermines departmental efforts to regulate private- and public-sector 
compliance with NPDB requirements.  
Furthermore, since HHS policy and procedures require that PSC report to State licensure 
boards at the time a report is submitted to the NPDB, failure to report to the NPDB  
deprives State licensure boards of potentially useful information for their regulatory 
activities.  According to the Federation of State Medical Licensing Boards, the majority of 
State medical boards require that medical malpractice claims, judgments, and/or 
settlements be reported to them.  Nineteen of these boards provide malpractice history as 
part of their publicly available physician profiling information.  In a September 14, 2004, 
e-mail, FSMB advised OIG that compliance with reporting requirements . . . is essential 
in assuring that state medical boards receive sufficient information to evaluate the 
performance of licensees in fulfilling their responsibilities of public protection. 
Several Factors Influence Reporting to the NPDB 
Lost Files 
Before PSC files a report with the NPDB, it sends the case file to agencies for final 
verification that information is accurate and complete.  According to HRSA, eight cases 
that PSC sent to HRSA during 1997 and 1998 have been lost.  According to NIH, five 
cases PSC sent to NIH during the period 1997 through 2002 have been lost.  Both 
agencies indicated that they would work with PSC to recreate the files. 
OEI-12-04-00310  HHS Agencies Compliance With the National Practitioner Data Bank Malpractice Reporting Policy 
5  Incomplete Records 
According to PSC documents, as noted earlier, PSC is missing peer review determinations 
for 28 HRSA cases and 10 IHS cases. PSC is also missing practitioner identification 
information for 73 HRSA cases, 33 IHS cases, and 2 NIH cases.  PSC would need this 
information to complete the reporting process to the NPDB.  
Medical Claims Review Panel Decision 
One cause of the missing practitioner identification information is a 1998 decision by the 
Medical Claims Review Panel (then called the Quality Review Panel) to forgo naming a 
practitioner when the standard of care was met.  Practitioners names are a required data 
element for NPDB reporting; therefore the decision, which was inconsistent with the 
October 1990 PHS policy directive, effectively makes it impossible to report these cases 
to the NPDB. 
According to HRSA, in addition to the 1998 Medical Claims Review Panel decision, the 
decision to forgo naming a provider was sometimes caused by the necessity of obtaining 
. . . feedback from the PSC Claims Office or OGC in certain situations as to the rationale 
for the payment in settlement or litigation.  
HRSA also advised OIG that There are other practical reasons for missing practitioner 
identification information . . . .  HRSA indicated that these reasons include the following: 
 	 Many cases were filed years after the alleged incidents, and, since they took so 
long to reach settlement or go through litigation, in many instances relevant data or 
records were misplaced or lost.  HRSA is attempting to retrieve or regenerate this 
information. 
 	 Many HRSA-funded health centers that have been sued under the FTCA may have 
been unaware of the importance of keeping for years certain files containing 
information necessary for NPDB reporting. 
 	 In some cases, HHS peer reviewers were advised that payments were made for 
the convenience of the government in settling certain claims to avoid the costs of 
litigation. According to HRSA, it is difficult in these situations to assign 
responsibility to a particular practitioner. 
Failure to Replace Key Official  
Finally, in addition to the above problems, we identified an additional impediment to 
reporting. In June 2003, the PSC Claims Officer retired.  Prior to his retirement, he was 
the official whose name and telephone number had appeared on the report sent to 
OEI-12-04-00310  HHS Agencies Compliance With the National Practitioner Data Bank Malpractice Reporting Policy 
6  practitioners and therefore he was the individual they would call.  When he retired, his 
name was removed from HHS medical malpractice reports; in lieu of his name, PSC 
inserted PSC Claims Officer.  Because there is no longer a Claims Officer, and because 
HHS components have yet to agree on new reporting procedures, practitioners have no 
identifiable HHS contact. 
In addition to the unresolved issue of an HHS contact for practitioners, the actual 
responsibility for entering reports into the NPDB remains a problem.  The PSC Claims 
Officer was responsible for actual data entry of reports.  Because of his retirement, the fact 
that he was not replaced, and organizational changes involving the planned relocation of 
the PSC Claims Office to OGC, the responsibility for data entry of reports to the NPDB 
has not been resolved. 
Last HHS Report 
For the period of our review, June 1997 through September 2004, we determined that the 
last HHS data entry to the NPDB was made on July 30, 2003, when two HRSA cases 
were reported by one of the paralegal staff in the PSC Claims Office.  According to PSC, 
an additional 23 HRSA cases were ready for reporting in July 2003.  However, after PSC 
had reported these two cases, it became concerned that because there was no official 
Claims Officer to assume legal responsibility for data entry, the 23 HRSA cases, as well 
as subsequent reports, should not be entered into the NPDB.    
AGENCY COMPLIANCE ACTIONS 
Staff-Level Discussions 
After we identified the underreporting problem in October 2003, we provided each agency 
with the PSC listing of unreported cases.  We then met with HRSA and IHS 
representatives, as well as PSC and OGC staff, on December 4, 2003, to discuss 
compliance.  While agency staff generally agreed to start working more closely with PSC 
to provide the information required for reporting, it was not clear whether they would 
fully comply with the current PHS policy.  For example, IHS staff advised OIG in a 
December 22, 2003, e-mail that The IHS will continue to work within the framework of 
the current HHS policy and report those cases in which a provider was found to be 
negligent . . . . However, IHS did not indicate that it would report cases where the 
standard of care was met, which is a requirement of current PHS policy (except when 
there has been a determination of a system breakdown).  At the December 4, 2003,  
meeting, HRSA and IHS staff expressed their personal opinions that the current PHS 
reporting policy should be revised so that the only cases reported by HHS would involve 
claims in which the standard of care was not met.  It should be noted that the private 
sector is required to report all medical malpractice settlements and judgments to the 
OEI-12-04-00310  HHS Agencies Compliance With the National Practitioner Data Bank Malpractice Reporting Policy 
7  NPDB, regardless of the standard of care determination.  The standard of care is not a 
consideration in the regulatory reporting requirements for the private sector.8 
IHS Corrective Action Activities 
An October 19, 2004, memorandum from the IHS Director to the Inspector General 
updated the IHS position, as follows:  
 	 Depending on the outcome of due process notification to providers, IHS will report 
up to 103 providers. 
 	 A detailed administrative process for reviewing and reporting medical malpractice 
claims has been developed; IHS has assigned a senior physician and one 
administrative employee to work on this process. 
 	 IHS believes that its reporting of providers who are not negligent in their care to 
the NPDB in accordance with current HHS policy could compromise the recruiting 
and retention of high-quality health care providers. 
 	 There are circumstances in which IHS contract providers are not covered by the 
FTCA.  IHS has identified 21 such providers. 
 	 IHS, NIH, and HRSA are pursuing a revision to the 1990 PHS policy on 

malpractice reporting to the NPDB. 

RECENT DEVELOPMENTS 
Relocation of Claims Office Staff to OGC 
On October 4, 2004, PSC Claims Office staff who had been processing medical 
malpractice cases were organizationally relocated to OGC; these former Claims Office 
staff now follow the same process for handling medical malpractice claims as they did 
when they were part of PSC. Also as a result of this reorganization, OGC, instead of PSC, 
currently maintains the list of reported and unreported medical malpractice cases.   
RECOMMENDATIONS 
We recommend that IHS, HRSA, and NIH each take steps to:  (1) implement a corrective 
action process that would address unreported cases, (2) improve internal controls 
involving case file management, and (3) assign staff to assume responsibility for 
addressing practitioner questions/complaints and data entry of reports to the NPDB. 
8 42 U.S.C.  11131 
OEI-12-04-00310  HHS Agencies Compliance With the National Practitioner Data Bank Malpractice Reporting Policy 
8  With respect to individual agency corrective action activities, we offer the following 
details. 
IHS 
As noted earlier, IHS has taken steps to address reporting to the NPDB.  In addition to 
planning to report 103 providers, IHS also indicated in its memorandum that it is planning 
to review the reporting status of the remaining cases.  We would appreciate receiving an 
update on IHSs efforts to address all unreported cases. 
HRSA and NIH 
As soon as possible, HRSA and NIH should implement a corrective action process for  
reporting cases. This should include reconstructing lost cases and, in instances for 
which OGCs listing of HRSA and NIH cases is missing information on the standard of 
care (met/not met) or practitioners name, provide such information for NPDB reporting 
purposes. In view of the large number of HRSA cases, HRSA may want to consider 
prioritizing cases so that practitioners with significant peer review findings involving 
deficient care can be reported at the earliest possible time.  Additionally, in accordance 
with current policy, reports to the NPDB should also be sent to the appropriate State 
licensing board(s). 
Both HRSA and NIH should review and improve internal controls, including the possible 
development of an agency tracking and case management file system, to ensure that: 
(1) cases are reported timely, (2) case files are not lost, and (3) information in files is 
maintained in accordance with record retention policies.  As part of this activity, HRSA 
should inform health centers of record retention requirements so that information required 
to be reported to the NPDB is maintained, notwithstanding the length of time between the 
onset of a medical malpractice case and reporting to the NPDB and State licensure boards. 
IHS, HRSA, and NIH 
In view of the retirement of the PSC Claims Officer, the relocation of the PSC Claims 
Office to OGC, and the fact that each agency has the most knowledge about its own 
practitioners peer review findings, OIG believes that the most effective management 
practice for implementing HHS medical practice reporting policy would be for each 
agency to designate an individual to handle practitioner inquiries.  This can be 
accomplished by each agency registering independently with the NPDB.  The NPDB 
online registration form allows for a point of contact for each registered entity.   
We also recommend, as an effective management practice, that each agency designate an 
individual to do data entry for NPDB reporting.  This would provide agencies with full 
control of their NPDB-related responsibilities.  
OEI-12-04-00310  HHS Agencies Compliance With the National Practitioner Data Bank Malpractice Reporting Policy 
9  SUMMARY OF THE DEPARTMENTS COMMENTS 
We received a response from the HRSA Administrator on behalf of the Secretary.  This 
response, which is attached as Appendix A to this report, indicated that the Department is 
working to develop a final action plan.  In developing this action plan the Department is 
reviewing policy options relating to what the future HHS reporting policy should be; it is 
anticipated that final action on a reporting policy will be completed in the fall of 2005. 
The Departments response also noted that agencies have implemented revised procedures 
to track new malpractice reports and that recommendations will be made to the Secretary 
to ensure greater compliance in the future. 
Finally, the response provided technical comments from HRSA, NIH, and IHS.  We have 
revised the report, as appropriate, in response to a number of the technical comments 
provided by these agencies. In addition to the changes in the body of the report, we have 
responded to agency technical comments as follows:   
NIH and IHS Comments Regarding VA and DOD Reporting 
Both NIH and IHS suggested in their technical comments that we include VA and DOD 
reporting policies and practices.  Although the background section of this report noted the 
existence of such policies, the purpose of this study was limited to HHSs compliance 
with its own reporting policy. We did not examine VA and DOD practices. 
HRSAs Comments Regarding the OIG Work Plan 
HRSAs technical comments indicated that this study was not part of the OIG Work Plan 
for FY 2004 or FY 2005. 
Page 7 of the FY 2004 OIG Work Plans Public Health Agencies Section included the 
following work plan proposal: Medical Malpractice Claims Against Health Centers. 
This study was to evaluate the timeliness of the review process for medical malpractice 
claims against health centers funded by HRSA.   During research for the study, we 
determined that we should stop work because the Department was reorganizing the 
processing function for medical malpractice claims, i.e., moving the Claims Office from 
PSC to OGC. However, before the project was cancelled, we had asked for data on the 
reporting of completed malpractice cases to the NPDB.  Based on the results of this 
request, we decided to review agency compliance with NPDB malpractice reporting 
requirements. 
HRSA Comments Regarding OIG Calculation of Unreported Cases 
According to HRSAs technical comment, our finding that as many as 474 cases have not 
been reported might be misunderstood because several of the cases included in this 
OEI-12-04-00310  HHS Agencies Compliance With the National Practitioner Data Bank Malpractice Reporting Policy 
10  computation were still under review and a determination of system breakdown could not 
have been made. 
We discussed this issue extensively with the Claims Office and it reaffirmed what it had 
initially advised us: based on peer review findings presented to the Claims Office, none 
of the cases included in our computations for this report involved a peer review 
determination of system breakdown. 
IHS Comments Regarding Missing Information 
IHS notes in its technical comments that PSC is also missing payment information from 
OGC on some claims, so that reporting to the NPDB is not possible for these claims. 
This technical comment apparently applies to IHSs experiences since they once again 
started reporting in April 2005. The focus of our discussion in the report on Missing 
Information was for the period covered by our review, June 1997 through September 
2004.  After IHS provided the technical comments to OIG as part of the signed 
departmental response, IHS advised OIG that the agency has been able to work with PSC 
to deal with the missing payment information. 
OEI-12-04-00310  HHS Agencies Compliance With the National Practitioner Data Bank Malpractice Reporting Policy 
11  APPENDIX A 

OEI-12-04-00310  HHS Agencies Compliance With the National Practitioner Data Bank Malpractice Reporting Policy 
12  OEI-12-04-00310  HHS Agencies Compliance With the National Practitioner Data Bank Malpractice Reporting Policy 
13  OEI-12-04-00310  HHS Agencies Compliance With the National Practitioner Data Bank Malpractice Reporting Policy 
14  OEI-12-04-00310  HHS Agencies Compliance With the National Practitioner Data Bank Malpractice Reporting Policy 
15