Who Signs What, and How Often?

     The past few months have seen several changes in patient signature requirements, including new rules for patient acknowledgment of services and a revised Advanced Beneficiary Notice form. I have received many questions about these requirements, and from them I sense some confusion. Of course, with the rules and regulations constantly changing, and with some of the rules seeming to contradict others, it's no wonder there is some doubt about exactly what signatures you need to obtain. So let's try to clear up some of these issues about who needs to sign what, and when.

The Trip Report
     The new "patient signature rule" is really for patients to acknowledge that they have received services. Many ambulance suppliers add language into the patient signature block about assignment of benefits and release of medical records, while leaving out any reference to the patient actually receiving the service. I discussed this rule in detail last year (Sign On the Dotted Line, September 2007). In a nutshell, patients are required to sign at the time of transport to show that they received services. If the patient is not able to sign, there are five other acceptable signatories. If none of them are available, then, and only then, the crew should sign and state why the patient was not able to sign for himself. Nothing prohibits throwing additional language into that signature block about financial responsibility, but the release of medical information is more appropriately covered by the HIPAA signature, which should be a separate signature line, because the patient is acknowledging two separate things.

Refusal Forms
     While few states require refusal forms, they are a good measure of protection. If the patient refuses service, having his signature stating that he understands the consequences of his decision can help limit your liability. Of course, if the patient is refusing transport, he may also refuse to sign anything (obstinate people can be that way), in which case your crew should sign the refusal, stating that it has been explained to the patient, but the patient refused to sign.

HIPAA Acknowledgement
     It still amazes me how many times I am asked by a medical provider to sign a HIPAA consent form. Consent forms were part of the proposed HIPAA Privacy Rule, but they were not a requirement under the final rule. The current requirement for HIPAA is that the patient receives a copy of your "Notice of Privacy Policy" and signs an "acknowledgement" that they have received it. That's it. There is no "consent" required for release of patient information for purposes of treatment, payment or healthcare operations. As long as your policy does not change, once a patient gets a copy and signs the acknowledgment, that signature is good for life. But unlike the signature rule above, if the patient cannot sign, there are only a few others who can sign in their place (parents of minor children or legal guardians under your state's laws, for example). So, if you do not get a signature at the time of transport, you should make an attempt to get the acknowledgment later.

The Revised ABN
     The Advanced Beneficiary Notice form has recently been revised. For ambulance purposes, the ABN is only required for trips that are not "reasonable and necessary," which basically means that the service can be brought to the patient cheaper than taking the patient to the service in an ambulance. The revision to the rule also allows using the form to notify the patient when the ambulance trip might not be covered for other reasons (i.e., it is not medically necessary or is not to the nearest appropriate facility). If you choose to use the ABN form for this purpose, it may help you with getting paid on denied claims later, and may remove the need for similar language in your general patient signature block.

The PCS Form
     I've discussed this requirement in the past (Physician Statements of Medical Necessity, May 2007), but I have not discussed who can actually sign these forms. This is one of those areas where the rules and publications seem to contradict each other. The rules (Code of Federal Regulations) seem to say that for some instances (mainly repetitive, nonemergent trips), these forms must be signed by a physician. However, other Medicare publications state that the form may be signed by an MD, PA, NP, CNS, RN or discharge planner. I personally like to see them signed by an MD just to avoid the issue, but there are times when no MD is involved in the patient's care. As to how often these forms must be signed, for a nonrepetitive, nonemergent transport (i.e., a hospital discharge or transfer), you should get a form for the specific date of service. For repetitive, nonemergent trips (e.g., dialysis) the forms are good for 60 days from the date they are signed.

     I hope this list is helpful and will serve as a reference for signature requirements. Of course, the rules may change again next week, so stay tuned. I'll keep you posted.

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. This article is not intended to be legal advice. Contact Chris at ckelly@emscltd.com.