If you are in the process of drafting a SRDP submission, you must use the new SRDP forms or risk CMS not accepting the disclosure into the protocol. Effective June 1, 2017, the Centers for Medicare and Medicaid Services’ (CMS) voluntary Self-Referral Disclosure Protocol (SRDP) requires parties to make self-disclosures using standardized forms provided by CMS.
These forms are designed to streamline the submission process for providers and suppliers, as well as facilitate timely review of the disclosures by CMS. CMS has included helpful examples to assist the disclosing party in completing the SRDP forms.
The new CMS Voluntary Self-Referral Disclosure Protocol forms contain the following four required components:
- SRDP Disclosure Form: Provides CMS with information about the disclosing party, including steps taken to prevent future noncompliance.
✓ Important to note: The disclosing party must quantify the pervasiveness of the noncompliance as related to other similar arrangements and identify the date that it discovered the noncompliance.
- Physician Information Form(s): A separate Physician Information Form must be submitted for each physician included in the disclosure.
✓ Important to note: The disclosing party can no longer provide summary information that relates to multiple physicians but may limit its legal analysis of the noncompliance to the elements of the applicable exception not met.
- Financial Analysis Worksheet: This worksheet quantifies the overpayment for each physician included in the disclosure and must be submitted in a format compatible with Microsoft Excel.
✓ Important to note: The financial information is limited to the DHS revenue calculation and does not require disclosure of the aggregate compensation provided to the physician.
- Certification: The initial disclosure and any related supplemental submission must include a certification signed by the disclosing party or, in the case of an entity, its Chief Executive Officer, Chief Financial Officer, or other individual who is authorized by the disclosing party to disclose the matter to CMS to certify the truthfulness of the information contained in the disclosure.
CMS has released special instructions for physician-owned hospitals and rural providers that failed to disclose physician ownership on any public website and in any public advertisement. This information is also available on CMS’s SRDP website.