Stay compliant: Learn about Medicare’s new signature guidance

Running a therapy practice means embracing new challenges and opportunities, especially with rapid advancements in tech and AI. You’re dedicated to helping clients, managing staff, and keeping your practice thriving. The last thing you need is a denied claim because you missed an update on signature rules and use of AI in documentation.  

To avoid this, check out this straightforward guide to help you navigate Medicare’s newest signature requirements and AI guidelines. Staying current ensures compliance and keeps your practice efficient. Let’s dive into this new recommendation, why it matters for your practice (even if you don’t see many Medicare clients), and what simple steps you can take to stay on top of it. 

What is the new guidance about? 

First, let’s clear up what this update is—and isn’t. Medicare released an updated compliance guidance document, which is different from a formal regulation. Think of it as a set of official instructions on how they want to see things done, especially regarding signatures and the use of AI for clinical notes. 

While this guidance comes from Medicare, it’s a good idea for every practice to pay attention. Historically, rules set by the Centers for Medicare & Medicaid Services (CMS) often become the standard that Medicaid and private commercial insurance companies follow. So, getting your practice aligned with these rules now can save you headaches later, no matter who you bill. 

Key updates in the guidance 

The update brings a few key changes to how you should handle signatures and documentation. Let’s break them down. 

• AI in documentation: If you use scribes or AI technology to help transcribe your session notes, this part is for you. The guidance clarifies that you, the clinician, must still personally sign and date the entry to authenticate it.  

• Stamped signatures: The rules around using a rubber stamp for a signature are very specific. Generally, stamped signatures are not accepted. The only exception is for a clinician with a physical disability who provides documentation proving they are unable to sign.  

• Attestations and signature logs: We’re all human, and sometimes a signature gets missed. For most medical records (but not orders), you can fix a missing signature by submitting a signed attestation statement. This is simply a document stating that you, the author of the note, are verifying its accuracy. 

If a signature is on the document but is hard to read, you can use a signature log. This is a typed list of your clinicians with their names and a corresponding handwritten signature. It helps reviewers identify who signed the note.  

Why this matters to your practice 

You might be thinking, “We don’t have many Medicare clients, so does this really affect us?” The short answer is yes, and here’s why. 

• Compliance across all payers: As mentioned, what Medicare does, other payers tend to follow. Adopting these standards now can help you stay compliant across the board, reducing claim denials and payment delays from private insurers and Medicaid. It’s about future-proofing your billing process. 

• AI is becoming the norm: This guidance is one of the first times CMS has specifically addressed AI in documentation requirements. It’s a clear signal that regulatory bodies are taking notice of new technologies in healthcare. We can expect to see more rules and guidelines related to AI in the future, so getting comfortable with the basics now is a smart move. 

• Avoiding claim denials: At the end of the day, this is all about getting paid for the incredible work you do. Clean documentation with proper, verifiable signatures is one of the easiest ways to ensure your claims are processed smoothly and without issue. Following these guidelines reduces your risk of frustrating and costly denials. 

Practical steps you can take to stay compliant 

Navigating these changes doesn’t have to be overwhelming. Here are a few practical steps you can take to ensure your practice is ready. 

1. Review your documentation process. Take a look at your current workflow. Are all notes being signed and dated by the treating therapist? If you use AI or scribes, make sure the final step always includes the clinician reviewing and signing off. 
2. Create a signature log. This is a simple but powerful tool. Type up a list of your clinicians’ names and have each one provide a handwritten signature next to it. Keep this file handy in case a reviewer ever questions an illegible signature. 
3. Know when to use attestations. Make sure your team knows that if a signature is missed on a progress note, they can complete an attestation statement.  
4. Check your electronic signature system. If you use an electronic health record (EHR), confirm that your system has the proper safeguards to prevent unauthorized changes and that it meets all legal standards for electronic signatures. 

How can practice management software help with this?  

Guidelines like these can often seem to add to the endless administrative tasks that can take time away from client care. Practice management software is designed to simplify these processes, allowing you to focus on what matters most. Look for features like these when choosing support tools:  

• Centralized signature management: Some practice management software allows secure electronic signatures to be stored and accessed in one place, eliminating the need for physical paperwork.  

• Customizable forms with e-signatures: Go for software that creates and sends intake or consent forms that patients can complete and sign electronically. 

With advanced tools and intelligent automation, the right practice management software can help you stay compliant while reducing administrative burdens and improving client care. 

Looking ahead: The future of AI in healthcare compliance 

This new guidance is more than just an update; it’s a sign of what’s to come. As technology, especially AI, becomes more integrated into healthcare, we can expect regulatory bodies to adapt with more specific rules. For practice owners and therapists, this means that staying informed and choosing tools that prioritize compliance will be more important than ever. 

Embracing technology that helps you meet these standards doesn’t just protect your practice—it also frees you up to spend more time with your clients. 

Navigating Medicare’s rules can feel complex, but with the right information and tools, it’s completely manageable. By understanding these updated signature requirements and taking a few proactive steps, you can ensure your practice remains compliant, efficient, and focused on delivering exceptional care. 

If you want to learn more about how Ensora Health can bring your practice into harmony, feel free to explore our solutions or reach out to our team. We’re here to help. 

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