Do Lifetime Signatures Still Exist?

Occasionally I get questions that mention “lifetime signatures,” and even more often I see the phrase signature on file on the patient lines of trip reports I review for clients.

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 disheartening to think that nobody was paying heed.

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 that there is no need to obtain one on each and every transport.

Let me give you four reasons why this is bad advice:

First, do you have the magic lifetime language in your signature block? In other words, does it say the patient agrees to assign their insurance benefits for direct payment to you and allows you to bill for this service or any other medical services provided in the past or future? If not, then the signature is only good for one trip. Of course this is easily fixed, so it is not a very big hurdle. But there are larger ones.

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 whom you have signatures for and whom you don’t? And how can you possibly expect crews in the field to know whose signature you have back in the office? For most EMS services this is simply impossible. The only category of patients to which this may realistically apply is frequent flyers, such as dialysis patients. So getting crews into the mind-set that there is a signature somewhere and therefore they don’t need to worry about obtaining one at the time of transport is dangerous policy! In my experience, once you tell crews they do not have to get certain documentation in some circumstances, you’ve guaranteed they never will try to get that documentation again.

Third, even if you have the “lifetime” form, can you find it? Time and time again I’ve seen trip reports that said signature on file but the office couldn’t locate it when I asked for it. 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 important, 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 prove successful if you have to defend your documentation practices. But beware, many of the auditors and Medicare administrative contractors (MACs), 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.

As an example, take this direct quote from the QIC (qualified independent contractor) 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.”

The QIC is not the only reviewer who feels this is the appropriate analysis; several of the MACs are using the same reasoning to deny claims. So if you don’t have them, your claim will be denied. And the only entity that will consider your technical argument is the U.S. District Court, which is the fifth level of Medicare appeal (which means you’ll be years and countless dollars down the road before anyone even listens to you).

If anyone has a basis to talk about how these “technical” arguments go, it’s me. I was the attorney who challenged CMS on the delay in the fee schedule and the sufficiency of Physician Certification Statements for repetitive patients. With each of these cases, I won based on the technical language of the law. The difference here is that I made those arguments because we as an industry had done the best we could, and CMS would not do its part, so it really picked 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.

The patient signature rule guidance published in 2008 made it clear CMS was looking for patients to acknowledge they’d received the services on each date of transport, and the underlying regulation supports that. In a nutshell the requirement is that a patient sign at the time of transport. If the patient can’t sign, there are five other acceptable signatories: the patient’s legal guardian, the patient’s healthcare power of attorney, a person who receives government benefits on the patient’s behalf, a person who arranges the patient’s medical appointments, or representatives of another provider who cares for the patient. If none of them are available, then and only then should the crew sign and state why the patient was not able to sign for themselves. The crew should also get the receiving facility to sign showing the patient was actually transported.

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, and at worst 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. He 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, reach Chris at ckelly@emscltd.com or by contacting EMS Consultants, Ltd. at 800/342-5460.