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Reporting Federal or State Health Care-Related Criminal Convictions
Health care-related criminal convictions that must be reported to the NPDB include criminal convictions, injunctions, and nolo contendere/no contest pleas related to the delivery of health care items or services.
Federal, state, and local prosecutors must report criminal convictions against health care practitioners, providers, or suppliers related to the delivery of health care items or services, regardless of whether the conviction is the subject of a pending appeal. For NPDB purposes, a criminal conviction includes:
- A judgment or conviction that has been entered against an individual or entity in a federal, state, or local court, regardless of whether an appeal is pending or the conviction or other record relating to criminal conduct has been expunged
- A finding of guilt against an individual or entity that is made in a federal, state, or local court
- A plea of guilty or nolo contendere by an individual or entity that has been accepted by a federal, state, or local court
- When an individual or entity has entered into participation in a first offender, deferred adjudication, or other arrangement or program where conviction has been withheld
Settlements in which no findings or admissions of liability have been made are statutorily excluded from being reported. However, actions that occur in conjunction with settlements in which no finding of liability has been made and that otherwise meet NPDB reporting requirements must be reported.
In addition to reporting initial health care-related criminal convictions, federal and state prosecutors also must report any revisions to previously reported actions, including when an action is on appeal. For more information, go to Types of Reports in this chapter.
Table E-21 outlines obligations for reporting federal or state health care-related criminal convictions.
| Law | Who Reports? | What is Reported? | Who is Reported? |
|---|---|---|---|
| Section 1921 | State prosecutors | Health care-related criminal convictions in state court | Practitioners, providers, and suppliers |
| Section 1128E | Federal prosecutors | Health care-related criminal convictions in federal or state court | Practitioners, providers, and suppliers |
Nolo Contendere/No Contest Plea
Federal and state prosecutors and investigative agencies must report nolo contendere/no contest pleas by health care practitioners, providers, or suppliers related to the delivery of a health care item or service. A plea of nolo contendere has the same effect as a plea of guilty as far as the criminal sentence is concerned, but it may not be considered as an admission of guilt for any other purpose.
Injunctions
Federal and state prosecutors and investigative agencies must report injunctions against health care practitioners, providers, or suppliers related to the delivery of a health care item or service.
First Offender, Deferred Adjudication, or Other Arrangement or Program Where Conviction Has Been Withheld
Federal and state prosecutors and investigative agencies must report a health care practitioner, provider, or supplier that has entered into participation in a first offender, deferred adjudication, or other arrangement or program where a conviction related to the delivery of a health care item or service has been withheld.
Sanctions for Failing to Report to the NPDB
If HHS determines that federal or state prosecutors have substantially failed to report information required to be reported to the NPDB, the name of the government agency will be published and made publicly available.
Table E-22 provides guidance on when federal and state health care-related criminal convictions must be reported to the NPDB.
| |
|
|---|---|
| A deferred adjudication for health care fraud in which the practitioner agrees to a 6-month probationary period and 4 months of community service in exchange for dismissing the case if the probation and community service are successfully completed. | Yes |
| The CEO of a health plan, who is a licensed physician, is convicted of embezzlement from the health plan and is sentenced to 4 years in prison. | Yes |
| A registered nurse is convicted of shoplifting. | No |
| A nurse's aide is convicted of abusing patients in a nursing home and is sentenced to 2 years in state prison. | Yes |
| Two owners/operators of two separate ambulance companies are sentenced for their part in a Medicaid fraud scheme; each is sentenced to 12 months and 1 day incarceration, to be followed by a 3-year supervised probation, and each is ordered to pay $2,000 in restitution. | Yes |
| A dentist files several false claims under her homeowner's insurance policy and is convicted of insurance fraud. | No |
| A man is sentenced for conspiracy to submit false Medicare claims in connection with his two durable medical equipment companies and his medical diagnostics company. His sentence includes a 21-month incarceration, payment of $1 million in restitution, and a 3-year supervised release. | Yes |
| A physician pleads nolo contendere to charges that she billed the Medicare program for services that were not medically necessary. | Yes |
| A health care provider pleads nolo contendere to insurance fraud not related to health care. | No |
| A practitioner pleads nolo contendere to shoplifting in a department store. | No |
| A hospital pleads nolo contendere to illegally paying physicians in exchange for referring patients to the hospital. | Yes |
| A practitioner has been harassing his ex-wife, who successfully seeks an injunction against him. | No |
| A court issues an injunction against a residential nursing facility to cease and desist using intimidation against the facility's residents to keep them from relocating. | Yes |
| A state court enjoins a company that owns a chain of diagnostic laboratories to stop discriminatory employment practices. | No |
Update October 2018
The following table describes changes made to the NPDB Guidebook. Style and formatting changes made throughout the Guidebook that do not affect the substance of the text are not indicated below. References to new figures added to this edition can be found in the Table of Figures.
- Added a new Q&A no. 8.
Sections Updated
