The Centers for Medicare & Medicaid Services (CMS) published revised documents and instructions for health care providers and suppliers to use when submitting self-disclosures to the Self-Referral Disclosure Protocol (SRDP) in September 2026. The purpose of these revisions was to reduce the administrative burden and clarify the information required for health care providers submitting SRDP disclosures. Health care providers and suppliers must use the updated SRDP forms beginning November 1, 2026.
As background, CMS established the SRDP pursuant to Section 6409 of the Patient Protection and Affordable Care Act, Pub. L. No. 111-148 (2010), which required the Secretary of Health and Human Services to develop a protocol that enables health care providers and suppliers to disclose actual and potential violations of the Ethics in Patient Referrals Act, 42 U.S.C. § 1395nn (the Physician Self-Referral Law). The Physician Self-Referral Law prohibits physicians from referring Medicare patients for certain designated health services to entities with which the physician (or an immediate family member of the physician) has a financial relationship, unless an exception applies. The Physician Self-Referral Law also prohibits an entity from billing for services provided pursuant to a prohibited referral.
The SRDP requires health care providers and suppliers reporting actual or potential noncompliance to submit an SRDP Disclosure Form, a Financial Analysis Worksheet, and, depending on the type of noncompliance: (i) a single Group Practice Information Form to report noncompliance resulting from a failure of a physician practice to qualify as a "group practice" pursuant to 42 C.F.R. § 411.352; and/or (ii) separate Physician Information Forms for each physician who made a prohibited referral to the entity, unless an exception (discussed below) applies.
CMS revised the various SRDP documents to reduce the administrative burden and clarify the information required for health care providers and suppliers submitting an SRDP self-disclosure.
First, CMS revised the SRDP documents and instructions to permit entities to submit one Physician Information Form to cover multiple physicians when the noncompliance is related to a failure of the physicians to satisfy the in-office ancillary services exception regarding the provision of a written disclosure for certain imaging services pursuant to 42 C.F.R. § 411.355(b)(7). In the supporting statement discussing these revisions, CMS notes that these changes are intended to decrease administrative burdens by no longer requiring the submission of "multiple, largely duplicative Physician Information Forms." See CMS, Supporting Statement-A, Medicare Self-Referral Disclosure Protocol (CMS-10328; OMB No. 0938-1106), p. 2 (May 22, 2025). CMS also acknowledges that these changes are consistent with the existing SRDP rule that permits entities to use one Physician Information Form to cover multiple physicians if the physicians "stand in the shoes" of a physician organization that is the subject of the disclosure. See id.
Second, CMS revised the SRDP instructions to explain that a disclosing party may satisfy its requirement to report and return overpayments arising from violations of the Physician Self-Referral Law by reporting and refunding the full overpayment directly to the party's Medicare Administrative Contractor, rather than submitting a self-disclosure via the SRDP. In the supporting statement, CMS explained that this approach could be less burdensome for some disclosing entities because, for example, the costs of preparing and submitting the self-disclosure could exceed the costs of the disclosed overpayment, or it could be desirable for business reasons to resolve the overpayment obligation prior to an imminent transaction. See Supporting Statement, p. 2.
Third, CMS revised the SRDP documents to clarify the type of information required regarding the date the entity first discovered the reported noncompliance. The Supporting Statement explains that the purpose of this revision is to decrease the likelihood that a party conflates (i) the date of discovery of potential noncompliance with (ii) the date a party completes its investigation and quantifies its overpayment. See Supporting Statement, pp. 2 – 3.
Important Takeaways
Though the Physician Self-Referral Law is a strict liability health care fraud and abuse statute that is nuanced and complex, the revisions to the SRDP documents and instructions illustrate that CMS is committed to reducing administrative burdens and providing clear instructions to providers who contemplate submitting SRDP self-disclosures regarding actual and potential noncompliance with the Physician Self-Referral Law. Health care providers and suppliers should review their arrangements that involve potential noncompliance with the Physician Self-Referral Law with experienced counsel to mitigate risk and determine whether an SRDP self-disclosure is appropriate.
For more information about the revised SRDP documents and instructions, or for help deciding whether an SRDP self-disclosure is right for your organization, please contact Alissa D. Fleming, Bernard Miller, or any other member of Baker Donelson's Health Law Group.