Fraud in the field: Signature compliance
EMS providers should be on high alert for fraud and forgery in the patient care report
By Daniel Pedersen, Esq., Page, Wolfberg & Wirth
We all use signatures in our daily life: signing credit cards receipts, writing checks and acknowledging legal documents. As healthcare providers, EMS crewmembers sign their name to PCRs to attest to patient care and might even sign their own name to authorize Medicare claim submission, meeting the requirements of 42 CFR 424.36(b)(6).
PCRs and signature forms, like checks and credit card receipts, are legal documents. But what about forged signatures? We would never forge a check, or sign someone else’s name on a legal instrument, right? So, why should EMS providers ever consider signing a patient’s name for claim submission purposes? Although it sounds bad, it’s happened – quite a bit. The fact that it’s occurring is alarming. The fact that it can often go undetected is even more alarming.
Recent cases of fraudulent EMS billing
Recent government investigations into fraudulent billing have many EMS providers on high alert for potential fraud – and rightfully so.
Two noteworthy examples in Texas and Kentucky involved ambulance company owners instructing crewmembers to intentionally omit patient information (e.g., if the patient walked to the stretcher), or otherwise document false information about the patient (e.g., bed confined status, when such was not the case). Both involved significant penalties to the company and the owners individually including, in one case, a 15 year jail sentence.
In a similar Pennsylvania fraud case, the owner of the company was more directly involved in altering the patient care reports and evidence surfaced of original patient care reports and modified versions – where the altered versions were relied upon for billing and represented false information about the patients. Specifically, the owner removed all references to the patients’ ambulatory status, in order to help establish the need for ambulance. This case also involved significant penalties and a jail sentence for the owner.
Applying the legal definition of forgery
Regardless of how or what crewmembers document (or are told to document) on a patient care report, billers and coders must still make an informed decision as to how to bill the claim. Thus, fraud potentially comes with billing decisions, and/or instructions from superiors, and not directly by actions (or inactions) of crewmembers.
That is, a crewmember can document that ALS care was provided (when it was really not), but if the claim is not billed at all, or only billed at the BLS level (and all coverage criteria for insurance are met), then there would likely be no fraudulent billing.
However, it might be very hard for a biller (or anyone for that matter) to detect a forged signature. Consider the numerous signatures required for ambulance transports:
- Patient (or representative) signatures for claim submission purposes and HIPAA NPP acknowledgement
- Crewmember signatures attesting to care provided
- Physician or other healthcare provider signatures (as permitted) for certificate of medical necessity (or PCS) purposes in non-emergency transport situations
If a crewmember forges someone else’s signature and a biller relies on that forged signature when billing insurance, it can become a fraudulent billing case, similar to those referenced above. But, the forged signature alone is also fraudulent.
For example, in Pennsylvania, “a person is guilty of forgery if (intending to defraud or under knowledge of facilitating fraud), he or she alters a writing without authority, or executes a document so that it purports to be the act of another who did not authorize the act.”
A crewmember signing a patient’s name without the patient’s consent meets the legal definition of forgery. The potential penalty for fraud lies with the perpetrator. It is not just a mistake that might result in potential Medicare overpayment (ultimately refunded by the company). It is a criminal act for which the forger can be personally liable.
Obtaining a patient signature
For Medicare claim submission purposes, there are numerous ways to obtain a patient’s signature for claim submission purposes, including:
- The patient
- Patient representatives (guardians, POA, family members, even facility representatives who previously cared for the transport)
- A combination of crew and receiving facility representatives acknowledging the patient was unable to sign and that none of the other representatives were willing or available to sign.
With all of these options, why would a crewmember ever have to forge the patient’s signature? Is it laziness? Is it not understanding the purpose of the Medicare regulations? Is it believing he or she will not get caught?
No matter the reason, the practice is illegal and should never be done. As care providers, we owe a duty to the patients. This duty extends far beyond simply providing pre-hospital care. It includes providing proper documentation of the care provided and meeting all compliance expectations including getting the patient signature (where the patient is physically and mentally capable of doing), or other valid signatures for claim submission purposes and not forging the patient’s signature.
Forging patient signatures is just not worth the risk, to you or the ambulance service.