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Question of a “Lifetime”

“Does Medicare still accept a lifetime signature for ambulance claims?”

As the AAA’s Medicare Consultant, I am frequently contacted by members seeking guidance on some of the more complicated aspects of Medicare billing. By a wide margin, the most common question we get is whether Medicare contractors will accept a so-called “lifetime signature.” Unfortunately, there is no easy answer to this question.

The Medicare regulations at 42 C.F.R. §424.36 provide that the beneficiary’s signature is required in order to authorize a healthcare provider to submit a claim to Medicare. The regulation then provides for two exceptions to that general rule. The first states that the beneficiary’s signature is not required if the beneficiary has died. The second states that, if the beneficiary is physically or mentally incapable of signing for themselves, the healthcare provider may obtain an alternative signature on the beneficiary’s behalf from one of the following individuals:

  1. The beneficiary’s legal guardian;
  2. A relative or any other person who receives social security or other governmental benefits on the beneficiary’s behalf;
  3. A relative or other person who arranges for the beneficiary’s treatment or exercises other responsibility for his or her affairs;
  4. A representative of an agency or institution that did not furnish the services for which payment is being claimed, but which did furnish other healthcare services or assistance to the beneficiary; or
  5. A representative of a Part A provider or nonparticipating hospital claiming payment for its services may sign for the beneficiary if, after making reasonable efforts, it is unable to locate or obtain a signature one any of the other authorized individuals referenced above. Note: this option is not available to Part B ambulance suppliers.

This regulation provides guidance on who may sign in order to permit a healthcare provider to submit a claim to Medicare. However, it does not speak to when that signature must be obtained. To answer that question, you must look to a separate regulation, 42 C.F.R. §424.40. That regulation sets forth the situations under which a request for payment (i.e., a patient’s signature) may be effective for more than one claim. Subpart (d) provides that a signed request for payment retained in a Part B supplier’s file may be effective indefinitely. It is this provision that ambulance suppliers have historically relied upon as justification for the use of a lifetime signature.

To understand how these provisions were intended to interact, it is helpful to keep in mind that the signature requirement applies to all Medicare claims, not only ambulance claims. This includes claims for services that can be provided on a non-assigned basis (e.g., physician claims). For these types of claims, the beneficiary’s signature is required to effectuate the assignment of benefits from the beneficiary to the healthcare provider, without which the healthcare provider would be limited to billing the beneficiary directly for its services. In other words, the beneficiary signature requirement was intended to perform a necessary administrative function.

However, in 2007 and 2008, CMS revised the beneficiary signature requirement for ambulance providers and suppliers. As part of these changes, CMS indicated that the beneficiary’s signature on a claim (or other documentation) served as proof that the ambulance services were actually rendered to the beneficiary. In other words, CMS clarified its belief that the beneficiary signature requirement performed a program integrity function.

This shift in CMS’ understanding of the purpose behind the beneficiary signature had far-reaching implications on the validity of the lifetime signature. When understood as a simple assignment mechanism, the lifetime signature is relatively non-controversial. After all, if the patient was willing to consent today to the submission of a claim to Medicare, why shouldn’t they also be able to consent to any future services rendered by that same healthcare provider? However, a patient’s signature obtained today would not establish that any future transports actually took place.

It is this shift in CMS’ stated position regarding the underlying purpose of the beneficiary signature requirement that has led a number of Medicare contractors to no longer accept a lifetime signature for ambulance transports. These contractors argue that a signature obtained prior to the actual date of transport cannot prove that the transport was actually provided. Frankly, I find it difficult to argue with their logic.

The problem is that, while CMS has announced its new position on the purpose of the beneficiary’s signature, it has yet to revise its regulations to specifically exclude ambulance providers and suppliers from relying upon a lifetime signature.

At some point, CMS will be forced to reconcile this apparent contradiction. In the meantime, ambulance providers and suppliers are forced to operate in something of a grey area. Operationally, the lifetime signature makes life a lot easier for our crews and billing office. However, relying upon the lifetime signature puts us at risk of having claims denied as part of an audit. The recent implementation of a prior authorization process for repetitive patients (currently in 8 states and the District of Columbia) has brought this issue to the forefront, as many ambulance services previously relied upon a lifetime signature for their dialysis and other repetitive patients.

So What Should You Do?

As a best practice, I strongly recommend that ambulance providers and suppliers instruct their crewmembers to attempt to obtain the patient’s actual signature or a valid alternative at the time of transport. Doing so should limit the situations in which the lifetime signature might come into play.

The question then becomes how to handle those claims where, for whatever reason, the crew was unable to obtain the patient’s signature or a valid alternative at the time of transport. In these situations, submitting the claim based on a previously obtained lifetime signature is an option. You will need to make a business decision on whether that option is the right one for your organization.

Some factors you should consider in making that decision:

  1. Has your Medicare Administrative Contractor indicated that it will no longer accept a lifetime signature for ambulance claims?
  2. Are you located in one of the states (or DC) where the MAC is currently operating a prior authorization process for repetitive patients? Are you currently under any other type of prepayment review?
  3. If claims are denied for lack of a valid patient signature, are you comfortable with potentially having to appeal all the way up to an Administrative Law Judge?

Depending on how you answer these questions, you may decide that the risks associated with relying upon the lifetime signature are too great. If so, whenever the crew fails to satisfy the patient signature requirement at the time of transport, and assuming you are otherwise unable to satisfy the new alternative for ambulance transports, you will need to send the patient a signature request form (and hold the claim until that request is returned).

So back to the original question: Does Medicare accept a lifetime signature for ambulance transport?
Answer: it depends on who you ask.

AAA members, do you have an issue you would like to see discussed in a future Talking Medicare blog post? Please write to me at

Brian Werfel

Brian S. Werfel, Esq. is a partner in Werfel & Werfel, PLLC, a New York based law firm specializing in Medicare issues related to the ambulance industry. Brian is a Medicare Consultant to the American Ambulance Association, and has authored numerous articles on Medicare reimbursement, most recently on issues such as the beneficiary signature requirement, repeat admissions and interrupted stays. He is a frequent lecturer on issues of ambulance coverage and reimbursement. Brian is co-author of the AAA’s Medicare Reference Manual for Ambulance, as well as the author of the AAA’s HIPAA Reference Manual. Brian is a graduate of the University of Pennsylvania and the Columbia School of Law. Prior to joining the firm in 2005, he specialized in mergers & acquisitions and commercial real estate at a prominent New York law firm. Werfel & Werfel, PLLC was founded by David M. Werfel, who has been the Medicare Consultant to the American Ambulance Association for over 20 years.

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