Medicaid sterilization consent forms: variation in rejection and payment consequences

OBJECTIVE

In 1974, the federal sterilization consent form (SCF) was created for those with publicly funded insurance to document appropriate informed consent by a clinician for sterilization procedures. This form must be signed by the clinician and the patient at least 30 days before the procedure and expires 180 days after being signed.¹ Although there are numerous barriers to desired sterilization, the Medicaid consent process is a major cause of unfulfilled sterilization requests.² As long as they comply with federal statutes, states may modify the Medicaid SCF, further complicating this process.³ However, data regarding this state-level variability are largely unavailable.⁴ Federal policy dictates that the global obstetrical fee should not be affected by SCF rejection.⁵ We sought to describe how individual state Medicaid policies differed in terms of what constitutes proper SCF completion and the payment ramifications of a rejected SCF.

STUDY DESIGN

A 25-question survey was administered with Qualtrics XM to 50 state Medicaid Directors in the United States or the most appropriate state official based on a review of the state website. The survey assessed state officials’ knowledge of the criteria used to assess the completion and validity of SCFs, SCF rejection rate, and payment ramifications for rejected SCFs. Data were collected from January 2020 to May 2020. Deidentified data were analyzed and reported in aggregate. This study was given an exempt status by the Tufts Health Sciences Institutional Review Board.

RESULTS

There were 41 responses from 36 states for a 72% participation rate. Four states had submitted multiple nonidentical responses. The criteria for SCF rejection included an incomplete form (n=35, 85%), mismatching or incorrect dates or time on the SCF (n=28, 68%), and that >180 days had passed since the patient’s signature, thus rendering the form expired (n=27, 66%) (Figure 1). Ten respondents (24%) estimated an SCF rejection rate of ≤10%, whereas 4 respondents (10%) indicated a >30% rejection rate (Figure 2). Most respondents indicated that the ramification of a rejected SCF included the loss of payment for the postpartum sterilization procedure for the provider (n=32, 78%) and the facility (n=29, 71%). Five respondents stated that a rejected SCF resulted in the loss of the entire obstetrical global payment for the provider and the facility (provider: n=5, 12%; facility: n=5, 12%).

FIGURE 1. Criteria for assessing and rejecting sterilization consent forms.

Listed are the various categories that state Medicaid offices use to assess and potentially reject submitted sterilization consent forms. The number and percentage of survey respondents that indicated each category were used by their respective state Medicaid office.

MCO, managed care organization.

Russell. Variation in sterilization consent form interpretation. Am J Obstet Gynecol 2020.

FIGURE 2. Estimated sterilization consent form rejection rate by census region.

Listed are the estimated sterilization consent form rejection rates by all respondents grouped by the US census regions.

Russell. Variation in sterilization consent form interpretation. Am J Obstet Gynecol 2020.

CONCLUSION

From our survey, it is clear that a wide variation exists between states or within individual states in the criteria used by state Medicaid offices to assess SCF completion, rate of rejections, and subsequent payment ramifications for providers and facilities. Most respondents identified objective measures (eg, incorrect dates) as major reasons to reject SCFs; however, many also used subjective reasons (eg, signature legibility). Although federal policy dictates that the global fee should not be affected by SCF rejection, our study found that 12% of respondents indicated a loss of the global fee.⁴ The fear of payment loss can be a significant barrier to desired sterilization. Ensuring greater transparency and consistency in the Title XIX sterilization consent process within and between states is a key step to ensuring equitable access to postpartum sterilization.