July 30, 2008

AAA MEMBER ADVISORY

TO:           AAA Membership

FROM:     Brian S. Werfel, Esq.

                 AAA Medicare Consultant

RE:            CMS Issues Formal Guidance on Patient Signature Requirement

On July 29, 2008, the Centers for Medicare and Medicaid Services (CMS) posted an educational document on its website, in which CMS provides formal guidance on the patient signature requirement for ambulance services.  The document summarizes the new exception for emergency ambulance transports that went into January 1, 2008, and also offers clarification on other aspects of the signature requirement. 

This guidance is the direct result of a request made of CMS by the AAA working closely with a team from American Medical Response spearheaded by Deb Gault.

The document can be viewed on the Ambulance Services Center page of the CMS website.  To access the document, go to http://www.cms.hhs.gov/center/ambulance.asp , and click on the link for "Guidance on Beneficiary Signature Requirements for Ambulance Claims" under "Policies/Regulations."

The Medicare patient signature requirement is set forth in 42 C.F.R. §424.36.  That regulation requires ambulance service providers and suppliers to obtain the signature of the patient before submitting a claim to Medicare, unless (1) the patient has died or (2) an authorized person has signed on the patient's behalf.

New Exception for Emergency Transports

The first part of the document summarizes the requirements needed to qualify for the new exception for emergency ambulance transports.  To qualify, an ambulance service provider or supplier must obtain the following:

·          A signed statement from an ambulance crew member stating that the patient was mentally or physically unable to sign at the time of transport and that no legally authorized person was available or willing to sign on the patient's behalf at the time of the transport;

·          Documentation of the date and time of the transport and the name and location of the facility that received the patient; and

·          Documentation from the receiving facility confirming the name of the patient and the date and time the patient was received by that facility.  This documentation can in the form of either: (1) a signed statement from a representative of the receiving facility at the time of transport or (2) a "secondary form of verification" received from the receiving facility at a later date.

Your Trip Report will typically satisfy the first two requirements, provided the crew properly documented that the patient was unable to sign and that there was no one to sign for the patient.

In the guidance document, CMS reaffirmed that you can meet the receiving facility requirement by adding an attestation clause and signature block to your trip report that would be signed by a representative of the hospital at the time of transport.  If you prefer, you could also have the representative of the hospital sign a separate form with the required information at the time of transport. 

Acceptable forms of secondary verification include a signed copy of your trip report (obtained after the fact), a hospital registration/ admissions sheet, a patient's medical record, a hospital log, or other internal hospital record.

Clarification Regarding Facility Representative's Signature

In the second part of this guidance document, CMS reiterated that ambulance service providers and suppliers can submit claims to Medicare, for both emergency and non-emergency transports, whenever the ambulance service provider or supplier obtains a signature on the patient's behalf from a facility representative.  This exception is set out in 42 C.F.R. §424.36(b)(4).  To qualify for this exception, the following conditions must be met:

·          An employee or representative of the facility must sign a form acknowledging: (1) the name of the patient, (2) the fact that the patient was transported by the specific ambulance provider or supplier to the specified facility on the specified date, and (3) that the facility representative is signing for the purpose of allowing the ambulance provider or supplier to submit a claim to Medicare for the transport; and

·          The facility must have provided care, services or assistance to the patient.

Note: the exception in 42 C.F.R. §424.36(b)(4) does not distinguish between the sending and receiving facility.  Therefore, as long as the sending facility provided care, services or assistance to the patient, a representative of that facility can sign on the patient's behalf.  The form signed by the sending facility's representative should acknowledge that the patient was transported from that facility by the ambulance service provider or supplier on that date.

CMS also reiterated that the facility representative's signature does not need to be on the claim form.  Instead, CMS agrees that the facility representative can sign a form created by the ambulance provider or supplier, or can sign a form prepared by the facility for this purpose.

To rely upon this provision, CMS believes the ambulance service provider or supplier must first use "reasonable efforts" to obtain the patient's signature.  However, CMS has stated that the "reasonable efforts" requirement will be satisfied whenever the ambulance service provider or supplier has "a reasonable basis for believing that a beneficiary is physically or mentally incapable of signing the claim at the time of transport, and that this disability will continue indefinitely".  As an example, CMS listed a patient known to have a significant form of dementia; in such cases, the ambulance service provider or supplier would not need to make any additional efforts to get the patient's signature beyond those made at the time of transport.  Other potential examples include patients with permanent paralysis, amputations or other permanent mental deficits where it is reasonable for the ambulance service provider or supplier to assume that the patient will never be able to sign.

In the guidance document, CMS stated that this "reasonable efforts" requirement would also apply to those situations where you got a signature on the patient's behalf from a personal representative (e.g., a legal guardian, spouse, daughter, etc.).  Note: the "reasonable efforts" requirement would NOT APPLY to situations where you have met the new exception for emergency ambulance discussed above.  This "reasonable efforts" requirement will be addressed as part of the AAA comment letter to the current proposed rule on the patient signature requirement.

Clarification Regarding Facility Liability

In the final part of the guidance document, CMS clarified that a facility would not become financially responsible for the ambulance transport if their representative signs your trip report or signature form.  Rather, CMS confirmed that the facility representative's signature simply authorizes you to submit a claim to Medicare for the ambulance transport.  Thus, this guidance document can be used to educate facilities that have, up till now, been reluctant to provide signatures, fearing that their signature would make them financially responsible for the transport. 

Note: On July 7, 2008, CMS issued a proposed rule that would make further changes to the patient signature requirement, including expanding the current exception for emergency ambulance transports to also cover non-emergency transports. CMS stated that it would update this guidance document if these changes are finalized.