October 29, 2010 — Increasing efforts in the payer community, especially Medicare, to find and reduce the number of payments made in “error” are resulting in more requests for patient records.
This hunt for “errors” has stimulated certain new trends in healthcare record keeping requirements and demands that can easily take even the most conscientious doctor of chiropractic by surprise.
One such trend is the demand in Medicare and increasingly in private insurance for original, clear and complete signatures by the attending provider on all patient records.
In fact, signature issues were recently cited by one Medicare official as the most common reason for rejecting all categories of claims by that federal program. It is important to note that the absence of a legible signature of the doctor or other clinician who provided a billable service can and does result in denial and recoupment of previously paid benefits.
Claims where a signature stamp is used, initials only, a last name and first initial and other variations are now being aggressively seized upon as a basis for rejecting claims. Where Medicare leads, private insurance follows.
This new reality means that all doctors of chiropractic need to sharpen their office procedures to make legible, complete and timely signatures a standard part of their record-keeping protocols and also to start looking back at recent clinic records and review all such documentation both for completeness and for signature.
A signature is a well accepted method for authenticating, validating or approving information. Unsigned documents almost always signal the process is incomplete or unauthorized, and the lack of a signature can easily undermine a doctor’s defense in any courtroom, third-party payment or state regulatory board setting. Also, in this age of informed consent, where agreement or consent is required, a document unsigned by the patient indicates it has not been given.
Palmetto GBA Medicare, one of the largest Medicare carriers recently posted the following list of unacceptable types of signatures for clinical records:
• Signature “stamps” alone in medical records are not recognized as valid authentication for Medicare signature purposes and may result in payment denials by Medicare
• Reports or any records that are dictated and/or transcribed, but do not include valid signatures “finalizing and approving” the documents are not acceptable for reimbursement purposes. Corresponding claims for these services will be denied.
• Illegible signature not over a typed/printed name, not on letterhead and the documentation is unaccompanied by:
1.) A signature log or
2.) An attestation statement
• Initials not over a typed/printed name unaccompanied by:
1.) A signature log or
2.) An attestation statement
• Unsigned typed note with provider’s typed name
• Unsigned typed note without provider’s typed/printed name
• Unsigned handwritten note, the only entry on the page
The consequences of a rejected signature are, very simply, a rejected claim.
While no Medicare carrier representative will confirm that instructions from Medicare’s Baltimore headquarters to fully exploit the signature issue to deny claims have, in fact, been handed down, the nationwide wave of activity on signature–based claims denials in all professions would seem pretty good evidence that this has, indeed, been the case.
What is an acceptable signature? Here is where things get interesting. Medicare is very clear; signature stamps are not acceptable for Medicare and Medicaid claims.
Many private insurance carriers will also no longer consider a stamped signature as authentication of who delivered a service. A full, legible, “indelible” meaning in ink not in pencil, signature is clearly the gold standard.
Palmetto even goes so far as to say that the presence of an illegible signature over a typed or printed name or an “illegible signature where the letterhead, addressograph or other information on the page indicates the identity of the signator can be acceptable.
What is important is that in every case where a signature is required for claims filing purpose, the doctor be aware of and in compliance with the official signature rules of all carriers.
Today, however, health information is just as likely to be produced electronically as it is to be on paper. To facilitate business, including the business of healthcare, most states have adopted an electronic signature law that allows individuals to apply an electronic signature as a valid, legal and acceptable authentication of documents submitted.
An electronic signature is generally understood to be any electronic means that indicates that a person adopts the contents of an electronic message. The United States Code formally defines an electronic signature for the purpose of US law as “an electronic sound, symbol, or process, attached to or logically associated with a contract or other record and executed or adopted by a person with the intent to sign the record.”1
The ability to send a legal signature electronically first was widely applied to faxed documents but increasingly, more sophisticated “encrypted” digital signatures are being used through computers and the Internet in e-commerce as well as in public filing of documents such as tax returns. Digital signatures are seen as being more secure than a simple generic electronic signature.
Chances are the majority of DCs are using some form of electronic signatures right now. What is of vital importance is for each doctor to be fully aware of the electronic signature laws in their state or jurisdiction and to be aware that the security of their electronic signature is a matter of immediate and urgent importance, just like a credit card number or even cash.
Again, Palmetto GBA2 has the following advisory points on their website regarding what is an acceptable electronic signature for Medicare purposes: www.palmettogba.com/palmetto/providers.nsf/vMasterDID/84HT746343;
• Chart “Accepted By” with provider’s name
• “Electronically signed by” with provider’s name
• “Verified by” with provider’s name
• “Reviewed by” with provider’s name
• “Released by” with provider’s name
• “Signed by” with provider’s name
• “Signed before import by” with provider’s name
• “Signed: John Smith, MD” with provider’s name
• Digitized signature: Handwritten and scanned into the computer
• “This is an electronically verified report by John Smith, MD”
• “Authenticated by John Smith, MD”
• “Authorized by: John Smith, MD”
• ‘Digital Signature: John Smith, MD’
• “Confirmed by” with provider’s name
• “Closed by” with provider’s name
• “Finalized by” with provider’s name
• “Electronically approved by” with provider’s name
• “Signature Derived from Controlled Access Password”
There is no escaping this new dimension of documentation demands facing all healthcare professions. The good news is that a proactive, serious and fully implemented signature plan can save you and your practice no end of future headaches and that to implement such a plan just demands discipline.
No expensive software is needed and no expert consultants need to be brought in. You just have to do the work.
1 Public Law 106-229; June 30, 2000, Electronic Signatures in Global and National Commerce Act.
2 “Palmetto GBA is a wholly owned subsidiary of BlueCross BlueShield of South Carolina and is based in Columbia, South Carolina.”
Source: International Chiropractors Association, Stuart Hoffman; www.chiropractic.org