Signatures: The Hidden Risks of Initials

Across services, a provider signing the run report with their initials is as natural as breathing. CMS guidance supports this practice, listing initials along with a printed name as one of the acceptable forms of signature. Yet, this practice may be one of the industry’s biggest blind spots when it comes to compliance risks. The use of initials for provider signatures, or any other person’s signature on a run report, can quickly spiral into a document full of questionable signatures. In this article, we look at how a false sense of security around signatures can lead to misuse of initials by crew members and create a compliance risk. Because of this risk, the use of initials should be avoided, and ambulance services should seriously scrutinize the signatures their providers make for themselves and obtain from others.


Rule Review

Let’s start by quickly reviewing the rules for signatures.

In Medicare Program Integrity Manual Chapter 3 – Verifying Potential Errors and Taking Corrective Actions,, we are told “Medicare requires that services provided/ordered/certified be authenticated by the persons responsible for the care of the beneficiary[.]” In this same section CMS provides a list of allowed and disallowed signature formats.

Because an ambulance has at least two crew members (sometimes more) there is often a question of who has to sign the run report. CGS takes the stance that while the driver of the ambulance is part of the assessment and care of the patient, a transport claim will not be denied based on a missing driver signature since they are not the primary caregiver. However, CGS still considers the best practice to be including a valid signature from the driver and based on the CMS language quoted above, other MACs may require all crew members’ signatures on the run report.

Likewise, in 42 CFR 424.36, we are told “[t]he beneficiary’s own signature is required on the claim unless the beneficiary has died or [is otherwise incapable.]”

Despite the requirement for patient signatures, there is no formal guidance from CMS on what formats constitute a valid patient signature. This leaves initials in a gray area. In at least one case a MAC has considered patient initials to be a “mark” requiring a witness signature to support it. However, there is a strong argument for patient signatures to be treated the same as provider signatures, making initials valid.

Signatures on the run report are a major requirement for coverage of the transport. A false signature can create a false claim and medical record, which is a serious financial and professional issue. Now let’s look at how signatures are audited.


How are Signatures Audited?

Publicly available audit reports for ambulance services are difficult to come by. Which is why Palmetto’s practice of regularly releasing reports on their ambulance audit results is appreciated. These results, found here, show the focus on signatures (which normally account for one of the top denial reasons) is geared towards proper formatting. Here are some examples of the denial reason and recommendations in these reports:

  • “Documentation Received Lacks the Necessary Beneficiary or Authorized Representative Signature”
    • Review documentation prior to submission to ensure that the proper beneficiary or authorized representative signature is included and is legible
    • For illegible signatures, clearly print or type the full name of the owner of the signature
  • “Information Submitted Contains an Invalid or Illegible Provider Signature”
    • Verify that electronic signature meets the CMS signature requirements as listed in the article Medicare Medical Records: Signature Requirements, Acceptable and Unacceptable Practices located on our website
    • Print or type the rendering provider’s full name below or near the provider’s signature
    • For documentation that contains letterhead including the rendering provider’s full name, ensure that the name is clearly marked or circled to indicate the owner of the signature
    • Submit a valid Signature Log to the medical review department. For more information refer to the article Signature Guidelines for Medical Review Purposes (PDF).
    • Submit a valid Signature Attestation with any documentation that contains an invalid or illegible rendering provider signature. Do not resubmit altered documentation with late corrected provider signature. This will not be accepted by medical review. For an example of a signature attestation, refer to the article Medicare Medical Records: Signature Requirements, Acceptable and Unacceptable Practices located on our website.

In the current audit environment, a MAC is more likely to tell you that you failed to properly support a false signature than tell you that you have one. Thus, the rules and how they are applied in audits miss certain compliance risks and feed into a false sense of security around the signatures themselves.


A False Sense of Security 

In our blog we have discussed the false sense of security ambulance services have with their documentation due to the honor system style billing and payment process of Medicare (and most other payers). Providers submit a bill, receive payment, and the documentation is never reviewed unless audited. Pre-payment review of the documentation for every medical bill is currently an impracticability. Only in very specific circumstances will Medicare or another payer put a provider under pre-payment review. So, unless something bad has happened to your service after an audit, why worry?

A false sense of security also exists for signatures in audits. As shown above, a standard audit is not looking for false signatures. The resources involved in investigating false signatures are better spent after a whistleblower or some other form of investigation raises the suspicion. Thus, if false signatures aren’t being looked for, are they a concern?


Convenience Over Compliance

The issues raised above allow convenience to trump over a more compliant approach to signatures at ambulance services. Consider these scenarios:

  • A crew member is completing documentation between runs or at the end of a shift and finds themselves in a position where it’s easier to mark initials for everyone on the transport and close out the run than to keep it open and get everyone to login and sign.
  • A crew member forgets to get a patient signature or perhaps takes the misguided belief that they’re doing the patient a favor by initialing their name for them (patients may even ask the crew member to sign for them!).
  • A member of the QA team quickly checks to see whether any signatures were captured and neglects to check for the basic requirements of a valid signature, time stamps to confirm they were obtained in a timely manner, or compares crew signatures against a signature log.

In these scenarios no one is considering the danger to their professional life or their service’s existence. Yet the discovery of a false signature can impact a provider’s license and call into question the signatures on every run they were on and result in massive refunds by the service.

It is important to recognize that the current rules and auditing practices create a blind spot for initials as signatures and get out of the false sense of security this environment creates. Compliance is an always active pursuit, and it is up to your service to make new processes to protect your employees and your bottom line.


What Can We Do?

False signatures can be difficult to uncover but this issue is still worth being proactive against, especially as technology increases an auditor’s ability to investigate and UPICs continue to drill deeper into documentation to identify fraud and abuse.

Services should make an internal policy requiring crew members sign all run reports with their full signature. Along with that, obtaining a regularly updated signature log for all employees and using that signature log during your service’s QA process will help stamp out the practice of crew members using initials to sign for each other.

Additionally, services should make it a policy to consider any patient signature using initials to be a “mark” which is invalid without a proper witness signature.

If you’d like assistance implementing these policies and procedures or improving your QA process to incorporate signature reviews, we are happy to help! Please reach out to us here.