A recent alert went out from various Medicare contractors concerning the requirement for healthcare providers to include a legible signature on their documentation. It turns out that in some cases, providers are not signing their documentation at all!
Audits conducted by the Office of the Inspector General (OIG) and CERT (Comprehensive Error Rate Testing) have shown that there has been little compliance to the Medicare signature requirements found in the Medicare Program Integrity Manual found here: http://www.cms.hhs.gov/manuals/downloads/pim83c03.pdf
In addition, one Medicare contractor has traced back non-compliance issues in several documentation areas, and at the top of the list was “no physician name or signature” : http://tinyurl.com/nrwdmz
The OIG and CERT have made it clear that this requirement must be enforced and signatures (not initials), hand written or electronic (no rubber stamps), must be present on ALL documentation and must be legible. This requirement applies to documentation for ANY service performed and billed to Medicare.
This error will cause an overpayment and a recoupment of funds. To avoid these errors and, in the end, lost revenue, it is recommended that you make certain your documentation contains a legible signature of the person performing the service and include a signature sample when responding to records requests from Medicare.
Healthcare providers are busy– No doubt about it. But let’s make sure that they get paid for the services they are rendering by staying on top of the rules and regulations and in turn, helping them to stay compliant.