Health Care Fraud Self-Disclosure
The Provider Self-Disclosure Protocol (SDP) was created in 1998 so that individuals and entities subject to Civil Monetary Penalties can voluntarily disclose self-discovered evidence of potential fraud.
Why Self-Disclose?
Self-disclosure gives you the opportunity to avoid the costs and disruptions associated with a Government-directed investigation and civil or administrative litigation.
Who Can Use This Form?
Use this form to voluntarily disclose the conduct for which you as a person or organization may be liable.
You are eligible to report a self-disclosure if you are a:
- Health care provider
- Health care supplier
- Person subject to OIG’s CMP authorities found at 42 C.F.R. Part 1003
Self-disclosures are not limited to any particular industry, medical specialty, or type of service. For example, a pharmaceutical or medical device manufacturer may use the SDP to disclose potential violations of the Federal anti-kickback statute (AKS), section 1128B(b) of the Act, because such violations trigger CMP liability under section 1128A(a)(7) of the Act, a provision of the CMPL.
Who Should *Not* Use This Form?
- If you are an individual or entity under an Integrity Agreement, please read this FAQ. You must contact your OIG monitor before submitting a self-disclosure.
- Notifications of someone else's improper conduct must be submitted via the Hotline Complaint Form.
Submitting a Self-Disclosure
To learn more about self-disclosure submission requirements, including how to calculate damages, please refer to the OIG's Health Care Fraud SDP.
Submissions that do not include all the required information, does not conform to the requirements outlined in the SDP, or are not appropriate for resolution under the SDP may be rejected. The self-disclosure form will guide you through providing a complete submission.
During our review and resolution of these matters, OIG will comply with the Freedom of Information Act (FOIA), and the public disclosure of personally identifiable information is restricted by the Privacy Act. We may have additional questions regarding your submission once it has been reviewed.
If an entity determines that it has submitted claims for items or services provided by an individual who does not possess a valid license to provide those items or services, that entity may have liability under the Civil Monetary Penalties Law (CMPL), 42 U.S.C. 1320a-7a, for the submission of claims for items or services furnished by the unlicensed individual.
Items and services provided by unlicensed individuals are not payable by Federal health care programs.
If the items or services were directly billed by the unlicensed person, such as for physician services, then the appropriate measure of damages under the Health Care Fraud Self-Disclosure Protocol will be the total amount paid by the Federal health care programs for those items or services.
If the unlicensed person provided items or services that are not billed separately to Federal health care programs, then for purposes of resolving the self-disclosure, the OIG will use a proxy for damages.
In many cases, the appropriate proxy will be the disclosing party’s total costs of employing or contracting with the unlicensed person during the period of time the individual was not licensed.
OIG will not reduce the disclosing entity’s costs of employment by its Federal payor mix, as is the case in self-disclosures involving the employment of excluded individuals.
While no Federal health care program payments can be made for services provided by excluded individuals, unlicensed individuals cannot provide services regardless of payor.
The provision of health care by unlicensed individuals warrants a significant penalty, and the cost of employment is a reasonable proxy for the total claims submitted for items and services provided by an unlicensed person.
As with all settlements, the determination of the appropriate measure of damages will be made on a case-by-case basis, taking into account the facts and circumstances of the disclosure.
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