Home Health & Hospice Week

A beneficiary's John Hancock is not always required.

Good news, suppliers: There are situations in which a beneficiary's signature is not required on a Medicare claims form - despite recent statements to the contrary from the Centers for Medicare & Medicaid Services.

During an Open Door Forum for home health and durable medical equipment providers earlier this year, agency staff told participants that a beneficiary's signature is "always required" to submit a Medicare claim.

But there are exceptions to that rule, notes attorney Seth Lundy with the Washington office of Fulbright & Jaworski.

"If a supplier doesn't have personal contact with the beneficiary - for example, in a mail-order business - the supplier can sign the claim form on behalf of the beneficiary," Lundy notes.

The signature requirements for claims are set out in the law at 42 CFR 424.36. The general rule is that the beneficiary's signature is required on the claim unless the beneficiary has died, or in the following situations:

1. If the beneficiary is physically or mentally incapable of signing the claim, it may be signed on his behalf by (1) a legal guardian, a person who receives governmental benefits on the beneficiary's behalf, (2) a person who arranges for the beneficiary's treatment or exercises other responsibility for his affairs, (3) a representative of an institution that did not furnish the services for which payment is claimed but furnished other services to the beneficiary or - in the case that none of the above is available - (4) a representative of the provider or supplier claiming payment.

2. If a provider or supplier files a claim for services that involved no personal contact with the beneficiary, a representative of the provider or supplier may sign the claim on the bene's behalf. This exception is most applicable to mail order DME businesses.

3. Claims by entities that provide coverage complementary to Medicare. A claim by an entity that provides coverage complementary to Medicare Part B may be signed by the entity on the beneficiary's behalf.

4. The "good cause" exception. If good cause is shown, CMS may honor a claim signed by a party other than those specified above. This could involve a situation where a neighbor who lacks power of attorney has been assisting a beneficiary with her affairs, for example.

You should rarely use the good cause exception, according to Lundy - and pursuing it is often more trouble than it's worth. "Unless you're talking about something expensive like a power wheelchair, in one-off situations where the good cause exception comes into play, it's usually more costly for a supplier to fight the denial than to let it go," he says.