CMS Pub. 100-10, ch. 4, § 4580

A. Background

Regulations at 42 CFR 412.46 (one of the conditions at 42 CFR 412, Subpart C) require

hospitals to obtain only one signed acknowledgment from physicians who are being

granted admitting privileges at a particular hospital. The physician must complete the

acknowledgment at the time that he/she is granted admitting privileges at the hospital or

before, or at the time the physician admits his/her first patient to the hospital. When the

hospital submits a claim, it must have on file a signed and dated acknowledgment from

the attending physician that the physician has received the notice specified in 42 CFR

412.46(b). Existing acknowledgments signed by physicians already on staff remain in

effect as long as the physician has admitting privileges at the hospital.

Hospitals must meet the conditions specified in 42 CFR 412, Subpart C, to receive

payment under the PPS for inpatient hospital services furnished to Medicare

beneficiaries. If a hospital fails to comply fully with these conditions with respect to one

or more Medicare beneficiaries, 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.

B. Monitoring Requirements

At least annually, monitor hospitals to ensure that they are appropriately obtaining the

acknowledgment statements from physicians with new admitting privileges as required at

42 CFR 412.46. You may perform this annual monitoring requirement at one single time

or more frequently during each contract year. Perform this activity offsite or onsite the

hospital setting. To perform this activity, you must do the following:

 Be familiar with the hospitals' own internal procedures to secure the

acknowledgment statements from physicians (see §4580.A). Ensure that each

hospital, in your review area, is in compliance with the acknowledgment

requirement;

 Inform providers in your review area about your monitoring activities;

 Request from the hospitals a list of all physicians with new admitting privileges

for the year/period under review. The list should include the physician name,

Unique Physician Identification Number (UPIN), the date admitting privileges

were granted, the date acknowledgment was signed, and the date of the first claim

submitted to the FI for that particular physician, when applicable. As needed, you

may request copies of the signed acknowledgements for verification. Validate the

information received from the hospital against the claims data. Validate all

acknowledgements if there are 5 or less. For 6 or more acknowledgements, select

a random sample of the listed physicians. If a deficiency was found on the sample

validated, select and validate all or another random sample to ensure that a pattern

does not exist. You must determine what constitutes a pattern based on the

number of physicians’ first claims submitted by the hospital before the physician

signed the acknowledgement statements;

 Coordinate, as necessary, with the intermediary in your review area to facilitate

action by the Fiscal Intermediary (FI) or you when needed. For example, you

may coordinate with the intermediary to establish a mechanism to facilitate

reporting by the intermediary when the intermediary is aware/has knowledge of a

hospital not obtaining appropriate acknowledgment(s) before billing;

 As needed, request an improvement plan to correct any deficiencies that are

found;

 Report results into SDPS.

C. Reporting Requirements

If you determine that corrective action is necessary (i.e., the deficiency affects payment

under the PPS Program):

 Notify the intermediary of the deficiency for claim adjustment;

 Notify the hospital that it must correct the deficiency immediately. Concurrently,

inform the appropriate CMS Associate Regional Administrator through your

Project Officer; and

 If the problem continues, or a pattern of noncompliance is established, refer the

case to the appropriate CMS Associate Regional Administrator for further

action(s) through your Project Officer.