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KEPRO - Beneficiary and Family Centered Quality Improvement Organization (BFCC-QIO)
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healthcare professionals Physician Acknowledgement
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!

Background
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.

Physician Acknowledgement Monitoring Report Template
Click here to download the electronic report template for submission of your list of all new physicians with admitting privileges.

Instructions
Download the template to your computer and rename the file. Once completed, e-mail the template to physician-acknowledgement.KEPRO@hcqis.org.

QIOs may accept electronically signed Physician Acknowledgement Statements in their monitoring activities.

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