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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 by the President 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 ("SRDP") 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.

The SRDP requires health care providers of services or suppliers 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).  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.

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.

The SRDP (link below) was revised on May 6, 2011, to make editorial changes and to clarify the information that should be submitted by disclosing parties.  In addition to reporting the actual or potential amount due or owing, the SRDP now requires that as part of the initial submission to CMS, disclosing parties should provide the total amount of remuneration a physician(s) received as a result of an actual or potential violation(s) during the applicable “look back” period. 

Section 6409(c) of the ACA requires the Secretary to submit a report to Congress on the implementation of the SRDP not later than March 23, 2012.  CMS timely submitted the report to Congress.  A copy of the report is available below.

For further information about the SRDP and its requirements, as well as related Frequently Asked Questions, 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, 62KB] .  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.