/. 

""'CE 

DEPARTMENT OF HEALTH &. HUMAN SERVICES	 Office of Inspector General 

.("-"'''.0	 Washington , D. C. 20201 

OCT 1 1 2005 

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 

SUBJECT: HHS Agencies' Compliance With the National Practitioner Data Bank 

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 

fies; (3) a 1998 decision by the HHS peer review entity, the Medical Claims Review 

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. VA’s 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 privatesector 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. 

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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 Center’s (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

 PSC’s Claims Office staff collect medical records 

and other information related to the plaintiff’s 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 President’s 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 HRSA’s 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: 

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• 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, HHS’s 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 Department’s 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. 

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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 

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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 

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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 

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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 IHS’s 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 OGC’s listing of HRSA and NIH cases is missing information on the standard of 

care (met/not met) or practitioner’s 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. 

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SUMMARY OF THE DEPARTMENT’S 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 Department’s 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 HHS’s compliance 

with its own reporting policy. We did not examine VA and DOD practices. 

HRSA’s Comments Regarding the OIG Work Plan 

HRSA’s 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 Plan’s 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 HRSA’s 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 

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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 IHS’s 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. 

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APPENDIX A 

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