Physician Acknowledgement Monitoring
We are the Medicare Quality Improvement Organization, working to improve the quality of care for Medicare beneficiaries. Our site offers beneficiary and family-centered care information for providers, patients, and families. Welcome!
- Download the template below to your computer and rename the file to your facility's CCN, facility’s name, and today’s date. Please do not make changes to the format.
- Upload your Physician Acknowledgement Statements along with your template before you click submit. (You can combine the statements into one pdf.) We accept wet, electronic, and digitally signed Attestation Statements.
- You will receive further instruction from Kepro if deficiencies are found.
- Electronic Report Template (Excel Format) for submission of your list of all new physicians with admitting privileges
- Frequently Asked Questions (FAQ) Document (PDF)
Regulations at 42 CFR 412.46 (one of the conditions at 42 CFR 412, Subpart C) require hospitals that are paid under the prospective payment system (PPS) to obtain only one signed acknowledgement from physicians who are being granted admitting privileges at a particular hospital. The physician must complete the acknowledgement at the time that he or she is granted admitting privileges at the hospital or before or at the time the physician admits his or her first patient to the hospital.
When the hospital submits a claim, it must have on file a signed and dated acknowledgement from the attending physician that the physician has received the notice specified in 42 CFR 412.46(b). Existing acknowledgements signed by physicians already on staff remain in effect as long as the physician has admitting privileges at the hospital. Kepro will monitor this process on an annual basis. If a hospital fails to comply fully with these conditions with respect to one or more Medicare beneficiaries, the Centers for Medicare & Medicaid Services (CMS) may, as appropriate:
- Withhold Medicare payment, in full or in part, to the hospital until the hospital provides adequate assurances of compliance; or
- Terminate the hospital's provider agreement.
If you have any questions about Physician Acknowledgement, please send an email to PhysicianAcknowledgement@kepro.com.