Medical Practitioners Should Pay Attention To Self-Reporting Requirements

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Medical Practitioners Should Pay Attention To Self-Reporting Requirements

Medical Providers sometimes suffer a state licensing inquiry or disciplinary matter, credentialing action or criminal charge (“Adverse Legal Action”).  When that happens, the Medical Provider should consider the timeline required to self-report.  The time varies, can be before the Adverse Legal Action is pending, does not necessarily depend on the outcome of the Adverse Legal Action and is not excused even if the agency involved reports the matter.  Failure to self-report within the required period can, and often does, result in additional adverse consequences.

At the federal level, under federal statute 42 CFR §424.516(d)[1], within 30 days a physician, nonphysician practitioner, and/or a physician and nonphysician practitioner organization must report to their Medicare contractor any change of ownership, any adverse legal action, or a change in practice location.  Then, it gets more specific in that when there is a “final adverse action” under 42 CFR §424.502[2], which is defined as: (1) a Medicare-imposed revocation of any Medicare billing privileges; (2) suspension or revocation of a license to provide health care by any State licensing authority; (3) revocation or suspension by an accreditation organization; (4) conviction of a Federal or State felony offense (as defined in §424.535(a)(3)(i)[3]) within the last 10 years preceding enrollment, revalidation, or re-enrollment; or (5) an exclusion or debarment from participation in a Federal or State health care program.  Failure to comply with this reporting requirement may result in revocation of a provider’s Medicare enrollment.  “May” is a key word used in the statute.  It means that revocation is permissive, as opposed to mandatory.  That is where the Medical Provider’s counsel can develop an argument against revocation.  Revocation for failing to report and the duration of such revocation often depends on whether the Medical Provider has a history of Final Adverse Actions, the nature of any actions, and other information regarding the circumstances.

State licensing agencies also require disclosure of adverse legal actions, but the specific requirements differ from Medicare and from state-to-state and board-to-board.  Consistent across the states and boards is that a mandatory reporting event is something that reflects on a Medical Provider’s competence or character to practice medicine. Such events include arrest and pending or final actions by criminal authorities for any criminal or quasi-criminal offense, actions by a health care facility or health maintenance organization reflecting on patient care, including actions (1) that condition, curtail, limit, suspend or revoke privileges, or that are disciplinary; (2) by Department of Health or Senior Services administration; (3) by the Drug Enforcement Administration or any state drug enforcement agency; (4) by Medicaid, Medicare, CHAMPUS, or other governmental insurance program; (5) by professional review organizations or utilization review organizations; or (6) by a medical malpractice insurance carrier declining coverage or a continuation of coverage, assessing a surcharge based on claims experience, imposing new limitations or restrictions on practice, or requiring remedial education or office monitoring.

Private insurer payor contracts, hospital medical boards and other credentialing entities may also require a Medical Provider to self-report certain actions, which are typically governed by the contract and vary.

Medical Providers should not wait to analyze reporting requirements until after an Adverse Legal Action is completed.  Health Care Regulatory is one of Epps & Coulson, LLP’s core practice areas.  If you have questions, call us – we’ve dealt with it and solved the problem for clients.  Please contact Dawn at:

Information contained in this Memo is intended for informational and educational purposes only and does not constitute legal advice or opinion, nor is it a substitute for the professional judgment of an attorney.  It is likely considered advertising.  Epps & Coulson, LLP encourages you to call to discuss these matters as they apply to you or your business.

Attorneys admitted to practice in California, New York, Colorado, Texas, and Oregon


[1] 42 CFR § 424.516 – Additional provider and supplier requirements for enrolling and maintaining active enrollment status in the Medicare program. | CFR | US Law | LII / Legal Information Institute (

[2] 42 CFR § 424.502 – Definitions. | CFR | US Law | LII / Legal Information Institute (

[3] 42 CFR § 424.535 – Revocation of enrollment in the Medicare program. | CFR | US Law | LII / Legal Information Institute (