Ownership Disclosure in Credentialing

Ownership disclosure is a key requirement when credentialing your practice or providers with insurance payers, including Medicare, Medicaid, and most commercial insurers. Understanding what ownership disclosure means, why it is necessary, and what information you need to provide will help ensure your applications are processed smoothly and in compliance with regulations.

What Is Ownership Disclosure?

Ownership disclosure is the process of reporting who owns, controls, or has a significant interest in your healthcare organization. This includes both individuals and businesses that have a direct or indirect stake in your practice. The purpose is to provide transparency about who is financially and operationally responsible for the organization.

Why Is Ownership Disclosure Necessary?

Ownership disclosure is required for several important reasons:

• Regulatory Compliance: Federal and state laws (such as 42 CFR §455) require healthcare providers to disclose ownership and control interests as a condition of participation in government programs like Medicaid and Medicare.

• Fraud Prevention: Disclosing ownership helps prevent fraud and abuse in healthcare by making it easier for authorities to identify conflicts of interest, improper relationships, or excluded individuals/entities.

• Transparency: Insurers and government agencies need to know who is responsible for the organization’s operations and finances, especially in the event of legal or compliance issues.

• Contractual Requirement: Most payers will not process your credentialing application or pay claims unless you have submitted a complete and accurate ownership disclosure.

Who Must Disclose Ownership?

• Individual Providers: If you are a solo practitioner, you must disclose your own information.

• Group Practices and Facilities: All individuals or entities with a direct or indirect ownership or control interest of 5% or more must be disclosed. This includes partners, shareholders, board members, and managing employees.

• Managing Employees: Individuals who have operational or managerial control, even if they do not have an ownership stake, must also be disclosed.

What Information Is Needed?

You will typically need to provide the following for each owner or controlling party:

• Full legal name

• Address

• Date of birth (for individuals)

• Social Security Number (SSN) (for individuals, as required by federal law)

• Ownership percentage or control interest

• Type of ownership or control (e.g., direct owner, indirect owner, managing employee)

• Relationship to other owners (for individuals, such as spouse, parent, child, sibling, or none)

• Disclosure of other entities owned (if an owner also has an interest in other healthcare entities)

• Information about managing employees and board members (even if they are not owners)

When Is Ownership Disclosure Required?

• Initial Credentialing: When first applying to join an insurance network or government program.

• Recredentialing or Renewal: Typically every three years, or as required by the payer.

• Change of Ownership or Control: Within 35 days of any change in ownership, control, or managing employees.

• Upon Request: At any time if requested by a payer or regulatory agency.

What Happens If You Don’t Disclose?

Failure to provide complete and accurate ownership disclosure can result in:

• Delays or denials of your credentialing application

• Suspension or termination of your participation in insurance networks

• Withholding of payments

• Potential legal or regulatory penalties

Best Practices

• Be thorough and accurate: Double-check all information before submitting.

• Update promptly: Notify payers immediately of any changes in ownership or control.

• Keep records: Maintain copies of all disclosure forms and supporting documents.

• Consult regulations: Review payer-specific and state requirements to ensure compliance.

Summary Table: Key Points

Requirement	Details
Who must disclose	All individuals/entities with 5%+ ownership or control; managing employees
What to disclose	Name, address, DOB, SSN, ownership %, type, relationships, other entities
When to disclose	Initial credentialing, recredentialing, changes, or upon request
Why it’s required	Compliance, fraud prevention, transparency, contractual obligation
Consequences of non-disclosure	Application delays, payment holds, network removal, penalties