‘Signature on File’: Do ‘Lifetime’ Signatures Still Exist?

Occasionally I will get a question that mentions “lifetime signatures,” and even more often I will see the phrase “signature on file” on the patient line of a trip report I’m reviewing for a client. At first I thought people were just not paying attention to the signature rule clarification CMS published in 2008, which made it clear they wanted a signature for each transport. Since I have been warning people about signature rule compliance constantly since then, it was a little disheartening to think nobody was heading my warning. But more recently I came to learn that, in fact, some in the industry are advising EMS providers that lifetime signatures are still acceptable and there is no need to obtain one on each and every transport. Let me give you four reasons why that is bad advice.

First, do you have the magic lifetime language in your signature block—does it say the patient agrees to assign their insurance benefits for direct payment to you and to allow you to bill for this service, or any other medical services, provided to you in the past or future? If not, the signature would only be good for one trip. Of course, this is easily fixed, so it’s not a very big hurdle ... just keep reading.

Second, do you have a “lifetime” signature form for every patient? Even if you have the right language let’s face it—how are you going to keep track of who you have signatures for and who you don’t, and how can you possibly expect crews in the field to know which patients’ signatures you have back in the office? For most EMS services this is simply impossible. The only category of patients this may realistically apply to is frequent flyers, such as dialysis patients. So getting crews into the mindset that there is a signature somewhere and therefore they don’t need to worry about obtaining the patient’s signature at the time of transport is dangerous policy! In my experience once you tell the crew they do not have to get certain documentation in some circumstances, that’s a guarantee they will never try to get that documentation again.

Third, even if you have the “lifetime” form, can you find it? I have seen time and time again where a trip report has “signature on file” but the office was not able to locate it when I asked for it. Worse yet, if you can't find it when Medicare asks for it, you can end up on the wrong side of a huge repayment demand. But again, this problem can be fixed with good record-keeping practices.

Fourth, and most importantly, the idea that “lifetime” signatures are still acceptable is based on a technical argument that the “policy” about signatures CMS published in 2008 (relative to 42 Code of Federal Regulations 424.36) really didn't override another regulation (42 CFR 424.40) that still says there can be “lifetime” assignment of benefits. This is a clever argument, and may in fact prove successful if you have to defend your documentation practices. But beware, many of the auditors and Medicare administrative contractors, who initially review—and deny—claims, are looking for signatures for each date of service under section 424.36, and they do not seem to acknowledge the possible exception in section 424.40.

Let me give you an example—a direct quote—from the QIC for the Southeast region: “The carrier advised that the documentation did not include a signed form from the beneficiary/representative. Your reconsideration request states you provided information in accordance to Medicare Signature Rules. However, you did not provide documentation as outlined in (b)(5). Based on the above, we found that Medicare payment cannot be made for the ambulance transport.

(b) Who may sign when the beneficiary is incapable. If the beneficiary is physically or mentally incapable of signing the claim, the claim may be signed on his or her behalf by one of the following: (5) A representative of the provider claiming payment for services it has furnished if the provider is unable to have the claim signed in accordance with paragraph (b)(1), (2), (3), or (4) after making reasonable efforts to locate and obtain the signature of one of the individuals specified in these sections.”

And the QIC is not the only reviewer who feels this is the appropriate analysis. Several of the Medicare administrative contractors (MACs) are using the same reason to deny claims. So, if you don’t have the signature, your claim will be denied. The only place you’ll find someone to listen to your technical argument is in U.S. District Court, which is the fifth level of Medicare appeal—which means you are years and countless dollars down the road before anyone will even listen to you. I have successfully challenged CMS on the delay in the fee schedule and the sufficiency of Physician Certification Statements for repetitive patients, so I know how to make these technical arguments fly. The difference here is I made those arguments because we, as an industry, had done our part the best we could, while CMS would not do their part and instead chose to pick a fight with us. This “lifetime” signature issue is different. If you choose to ignore what CMS wants and look for an easier, less burdensome route, then you are choosing to pick a fight with them—one you will lose in the long run due to the cost of the fight, even if you win in the end.

The “patient signature rule” guidance published in 2008 made it clear they were looking for a patient to acknowledge that they have received the services on each date of transport, and the underlying regulation (42 CFR 424.36) supports that. In a nutshell, the requirement is that a patient sign at the time of transport. If the patient is not able to sign, there are five other acceptable signatories—the patient’s legal guardian; the patient’s healthcare power of attorney; person who receives government benefits on the patient’s behalf; person who arrange the patient’s medical appointments; or representatives of another provider who cares for the patient. If none of those are available, then and only then should the crew sign and state why the patient was not able to sign for themselves. And in that case be sure to also get the receiving facility to sign showing that the patient was actually transported.

So, if you have heard that “lifetime” signatures are still acceptable, be cautious. This advice could at best lull you into a false sense of security (see #1–3 above), and at worst (#4) it could set you up for a long and expensive legal battle just to try to prove a point and avoid losing a lot of cash!

G. Christopher Kelly is an attorney who focuses on federal laws and regulations as they relate to the healthcare industry, and specifically to the ambulance industry. Chris lectures and advises EMS service clients across the U.S. This article is not intended to be legal advice. For more information or specific questions, Chris can be reached at ckelly@emscltd.com or by contacting EMS Consultants, Ltd. at 800/342-5460.