Self-Referral Disclosure Protocol

Patient Protection and Affordable Care Act:

Section 6409 of the Patient Protection and Affordable Care Act (ACA) was signed into law on March 23, 2010. Section 6409(a) of the ACA required the Secretary of the Department of Health and Human Services, in cooperation with the Inspector General of the Department of Health and Human Services, to establish a Medicare self-referral disclosure protocol that sets forth a process to enable providers of services and suppliers to self-disclose actual or potential violations of the physician self-referral statute.

Health care providers of services and suppliers are required to submit all information necessary for CMS, on behalf of the Secretary, to analyze the actual or potential violation of Section 1877 of the Social Security Act (the Act). Providers of services and suppliers must use the forms included in the most recent OMB-approved collection instrument entitled CMS Voluntary Self-Referral Disclosure Protocol (SRDP) in order to utilize the SRDP. Earlier versions of these forms cannot be used. 

Beginning March 1, 2023, except as provided below regarding disclosures related to the failure of a physician-owned hospital or rural provider to disclose physician ownership on any public website and in any public advertisement, the required elements of a complete disclosure are:

• For disclosures of noncompliance arising from the failure of a physician practice to qualify as a group practice under § 411.352, the self-disclosure must include: (1) the SRDP Disclosure Form; (2) the Group Practice Information Form; (3) a Financial Analysis Worksheet; and (4) an acceptable Certification.
• For disclosures of all remaining types of noncompliance (i.e., disclosures of noncompliance other than (a) the failure of a physician-owned hospital or rural provider to disclose physician ownership on any public website and in any public advertisement, or (b) noncompliance arising from the failure of a physician practice to qualify as a group practice under § 411.352), the self-disclosure must include: (1) the SRDP Disclosure Form; (2) Physician Information Form(s); (3) a Financial Analysis Worksheet; and (4) an acceptable Certification.

See section IV of the CMS Voluntary Self-Referral Protocol for specific instructions on completion of the required forms.

The SRDP is intended to facilitate the resolution of only matters that, in the disclosing party's reasonable assessment, are actual or potential violations of the physician self-referral law. Thus, a disclosing party should make a submission under the SRDP with the intention of resolving its overpayment liability exposure for the conduct it identified. As provided in the physician self-referral law, no payment may be made for designated health services that are provided in violation of the physician self-referral law. Section 6409(b) of the ACA gives the Secretary of HHS the authority to reduce the amount due and owing for violations of Section 1877 of the Act.

For further information about the SRDP and its requirements, see the links below.  After reviewing the material below, if you have additional questions please contact the CMS Physician Self-Referral Call Center by e-mail at 1877CallCenter@cms.hhs.gov.

Special Instructions for Submissions to the CMS Voluntary Self-Referral Disclosure Protocol for Physician-Owned Hospitals and Rural Providers that Failed to Disclose Physician Ownership on any Public Website and in any Public Advertisement

CMS has provided special instructions for submissions to the CMS Voluntary Self-Referral Disclosure Protocol (SRDP) involving solely noncompliance with 42 CFR § 411.362(b)(3)(ii)(C) (requiring physician-owned hospitals and rural providers to disclose on any public website for the hospital and in any public advertisement that the hospital is owned or invested in by physicians).  The special instructions are available at  Physician Self-Referral Disclosure Protocol - Special Instructions for Violations of 42 C.F.R. section 411.362(b)(3)(ii)(C) (PDF) . Disclosures involving noncompliance with any other provision of the physician self-referral law, including disclosures involving mixed noncompliance with § 411.362(b)(3)(ii)(C) and noncompliance with any other provision of the physician self-referral law, should continue to follow the standard SRDP instructions.  

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