Although not identified specifically by the Centers for Medicare & Medicaid Services (CMS) as the reason for its recent attention to signature requirements, the findings presented in the November 2009 Comprehensive Error Rate Testing (CERT) report⁽¹⁾ must have raised the agency's collective eyebrows.

Specifically, CERT reported an increase in improper payments and in the national fee-for-service (FFS) paid claims error rate (PCER) from its November 2008 report. According to the 2009 report, these increases can be traced back to five changes (listed below) made to the review methodology approved by the Department of Health & Human Services Office of Inspector General (OIG).

• Consolidation of the Hospital Payment Monitoring Program (HPMP) and CERT, which increased the error rate for inpatient hospital claims.
• Strict adherence to documentation requirements outlined by policy;
• Disallowance of supplier documentation;
• Removal of billing history as a valid source of information; and
• Strict enforcement of signature requirements.

This last item is of greatest importance since, before the November 2009 report release, CERT contractors did not deny claims for missing signatures. However, as described later in this article, parts of this policy have changed, and the reason for that boils down to one factor: loss of Medicare payments.

Between the issuance of the November 2008 and November 2009 CERT report, the national PCER increased from 3.7 percent ($10.2 billion) to 7.8 percent ($24.1 billion).

Policy Change

After an OIG consultation on the above factor, CMS issued Transmittal 327 (http://www.cms.gov/transmittals/downloads/R327PI.pdf), which covers signature (both handwritten and electronic) guidelines for medical review, to inform its contractors to strictly adhere to the Medicare policy requiring legible signatures.

This transmittal also provides guidelines on the topic for the following healthcare providers: physicians, non-physician practitioners, suppliers submitting claims to Medicare fiscal intermediaries (FIs), Part A/B Medicare administrative contractors (A/B MACs), carriers, regional home health intermediaries (RHHIs) and/or durable medical equipment MACs (DME MACs).

These revised and new signature requirements apply to medical reviews conducted on or after the implementation date of April 16, 2010. CMS noted that all signature requirements are effective retroactively for the November 2010 report period, which includes all 2009 discharge and service dates.

Documentation Requests

Contractors may request any information they deem necessary to make a prepayment or postpayment claim review determination. This includes any documentation submitted with the claims as well as documentation solicited from the primary provider and its third-party providers. Contractors performing medical reviews (automated, routine or complex) may request the unsolicited supporting documentation accompanying the claim, but are not required to do so.

However, there are two exceptions to this rule. Contractors may deny without reviewing the attached or simultaneously submitted documentation under two circumstances:

• When policies (statutes, regulations, national coverage determinations [NCDs] and local coverage determinations [LCDs]) are clear and can serve as the basis for denial; and
• In instances of medical impossibility.

Signatures Required

Medicare requires that services ordered and provided be authenticated by the author through a handwritten or electronic signature. Stamp signatures are definitely not acceptable. If there are reasons for denial that are unrelated to signature requirements, the reviewer won't proceed to signature authentication.

As with many things related to Medicare, there are exceptions to the signature requirement rule, listed below:

• Facsimiles of the original written or electronic signatures are acceptable for the certifications of terminal illness for hospice.
• Orders for clinical diagnostic tests are not required to be signed.³ However, documentation of intent (e.g., progress note) from the treating physician must exist, and it must be authenticated.

⁽¹⁾ The November 2009 CERT Report can be found at www.cms.hhs.gov/CERT

https://www.cms.gov/apps/er_report/preview_er_report.asp?from=public&which=long&reportID=15.