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EMTALAFederal Law and the Medical Staff
Shaheed Koury, MD, MBA, FACEP
SVP & Chief Medical Officer
Quorum Health
Objectives
• Review EMTALA Law
• Clarify Key Terms
• Define Hospital and Physician Responsibilities
• Address Special Circumstances and Challenges
• Discuss EMTALA Investigation and Violation
Process
• Present Case Examples
• Questions
2
What is EMTALA?
Emergency Medical Treatment and Labor Act:
A Federal Law requiring Medicare participating
hospitals to provide a Medical Screening Exam
(MSE) and stabilizing treatment(s) for anyone that
presents to the hospital’s dedicated emergency
department requesting medical examination or
treatment, regardless of their ability to pay.
3
EMTALA History
• Enacted to prevent refusing the treatment of patients based
on financial status (or other discriminatory reasons),
sometimes referred to as “patient dumping”.
• EMTALA is not simply an “anti-dumping” law.
• EMTALA is a federally mandated standard of practice for
hospitals and physicians.
4
What must the hospital provide?
1. An appropriate Medical Screening Exam (MSE) to anyone who “comes to the emergency
department” and requests an exam or treatment.
2. Necessary stabilizing treatment to a person with an emergent medical condition (EMC), including
an individual in labor, regardless of their ability to
pay.
5
What must the hospital provide?
3. An appropriate transfer if:
– The individual requests the transfer,
OR
– The hospital does not have the capability or capacity to provide the treatment necessary to stabilize the EMC, and/or have the capability or capacity to admit the individual for treatment,
AND
the benefits of the transfer outweigh the risk
6
Additional requirements
4. The treatment must be the same that would be provided to any patient arriving with those signs and symptoms.
5. Treatment decisions must be made in a nondiscriminatory manner regardless of diagnosis (e.g., labor, AIDS), financial status (e.g., uninsured, Medicaid), race, color, national origin (e.g. Hispanic or Native American surnames), and/or disability.
7
Definitions
• “Hospital Property”
– Main hospital campus
– Parking lot
– Sidewalk
– Driveway
– Hospital departments
– Any building owned by the hospital within 250 yards of the main building.
8
Definitions
• “Comes to the Emergency Department”
– An individual requests examination or treatment,
OR
– A prudent layperson would believe that the individual needs emergency examination or treatment.
9
Definitions
• Medical Screening Exam
– A Medical Screening Exam (MSE) is an exam performed by a qualified medical practitioner, to determine the presence, or absence, of an emergent medical condition.
– This includes the presence, or absence, of labor.
10
Definitions
• “Appropriate Screening”
– An MSE is the process required to reach, with
reasonable clinical confidence, the point at
which it can be determined whether the
individual has an Emergency Medical Condition
or not.
11
Definitions
• “Proper Screening”
– An MSE is an ongoing process, not an
isolated event.
– May be a brief history and physical
examination, or can include ancillary studies
and procedures.
12
Definitions
• “Emergency Medical Condition” (EMC)
– A medical condition manifesting itself by acute symptoms
of sufficient severity (including severe pain) such that the
absence of immediate medical attention could reasonably
be expected to result in:
◦ Placing the health of the individual (or, with respect to a
pregnant woman, the health of the woman or her unborn
child) in serious jeopardy,
◦ Serious impairment to bodily functions, or
◦ Serious dysfunction of any bodily organ or part.
13
Definitions
• “Emergency Medical Condition” (EMC)
– With respect to a pregnant woman who is
having contractions:
◦ There is inadequate time to effect a safe transfer to
another hospital before delivery, or
◦ The transfer may pose a threat to the health or safety
of the woman or her unborn child.
14
Triage is not a
Medical Screening Exam!
Triage simply means “to sort” the patient based on acuity.
Only a Registered Nurse can triage a patient.
Only a Qualified Medical Provider can perform a MSE.
Medical Screening Examination
15
Every patient is considered “emergent” until
determined otherwise by a Medical Screening
Exam performed by a QMP.
Medical Screening Examination
16
Medical Screening Examination
• You cannot delay the MSE to inquire about insurance or ability to pay for care.
• Even if it causes no delay, you cannot seek authorization from an insurer until the MSE is complete and stabilizing treatment is initiated.
17
The QMP has performed the Medical
Screening Exam…
Does an EMC Exist?
• If No, the patient is determined to have a non-emergent condition. No further obligation under EMTALA.
• If Yes, or EMC is not ruled out, then must:
– STABILIZE,
– ADMIT, or
– TRANSFER* *Appropriate Transfer
18
Definitions
• “Stabilized”
– Emergency Medical Conditions: No material deterioration of the patient’s condition is likely to result from discharge.
– Patients in Active Labor: The infant and the placenta have been delivered.
– Psychiatric Patients: Protected and prevented from injuring or harming him/herself or others.
19
Stabilizing Treatment
• Asthma Management – Bronchospasm
resolved
• Psychiatric Patient – No longer a danger to
self or others
• Broken Bone – Pain managed, fracture
splinted
• Woman in Labor – Delivery of child and
placenta
20
If a patient comes to the Hospital and is
determined to have an EMC following a MSE,
the Hospital must provide further medical
examination and treatment, including
hospitalization if necessary, as required to
stabilize the EMC within the capabilities of the
staff and facilities available at the Hospital,
including on-call physicians.
Stabilized
21
Within The Capabilities…
• “The hospital resources and staff
available
to inpatients…”
• “All resources available in the
emergency department.”
• “…the capability of its emergency
department includes the services of
its on-call physicians.”
• “The capability of the hospital
includes that of
the hospital as a whole…”22
When a Transfer Occurs:
• The hospital does not have the capacity or
capability to provide the treatment needed to
stabilize the patient for a discharge disposition,
and the benefits of the transfer outweigh the risk,
OR
• Patient request
23
Discharge versus Transfer
Confusing Terminology!
• “Stabilized”
– Stabilized for Discharge: No material deterioration of the patient’s condition is likely to result.
– Stabilized for Transfer: Benefits of transfer outweigh risks of transfer.
• SO …. “Unstable” then means:
– Unstable for Discharge: Material deterioration of the patient’s condition is likely to result.
– Unstable for Transfer: Risks of transfer outweigh the benefits of transfer.
24
Steps to ensuring an
Appropriate Transfer
1. Provide stabilizing treatment to the extent
possible given the hospital’s current capacity
and capability.
2. Obtain an accepting hospital with the capability
and capacity to treat the patient.
3. Completion of the “EMTALA Transfer Form.”
4. Send copies of the medical records/chart.
5. If the on call physician refused to respond need
to list their name and address on the form.
25
Related to Private Vehicles:
REMEMBER, when transferring a patient, “…the sending
hospital is ultimately responsible for ensuring that the
transfer is effected appropriately.”
There is no way to ensure that a patient will arrive at the
intended destination when transported by private vehicle.
Ask yourself:
“What is the best way to ensure that the patient
arrives at the receiving hospital?”
26
• When transferring a patient, the sending hospital is ultimately responsible for ensuring that the transfer is effected appropriately.
• There is no way to ensure that a patient will arrive at the intended destination when transported by private vehicle.
• CMS does not consider private vehicle an appropriate mode of transportation for an EMTALA transfer.
• Patients can make their own decision including deciding to self-transport (unless special circumstance such as involuntary psychiatric admission).
• The appropriate box is checked under section B and the patient disposition is transfer.
A Note about Private Vehicles:
NOTE: PRIVATE VEHICLE not considered
Appropriate Mode of Transfer and therefore not
an option to select.
Example: Standard Transfer Form
28
29
NEW29
30
Note about Non-EMTALA Transfers
• Applies to areas other than the ED, such as the
inpatient unit (EMTALA obligation ceases on
good faith inpatient admission).
• ED Transfers are treated as EMTALA Transfers.
31
On-Call Coverage Obligations
• The hospital is responsible for maintaining an on-call list in a manner that best meets the needs of its’ patients in accordance with the resources available to the hospital.
• The hospital must have written policies and procedures
to respond to situations where a particular specialty is
not available; where a hospital permits on-call
physicians to provide simultaneous call; where a
hospital permits physicians to schedule elective
surgery during call.
32
On-Call Coverage Obligations
Each Hospital must establish a process for
identifying those physicians “on-call” for a given specialty. On-call physicians, after being called,
must respond to the Dedicated Emergency Department as specified in the Hospital’s Medical
Staff Bylaws.
33
On-Call Coverage Obligations
The Hospital must document on the transfer
form the name and address of any on-call
physician who has refused or failed to appear
within a reasonable time to provide necessary
stabilizing treatment, and must report such
information to Hospital administration as soon
as possible.
34
Does a hospital violate EMTALA if
a patient refuses treatment?
• No, an individual may refuse to consent to examination and treatment, but only after the
hospital offers to provide further medical
examination and treatment and informs the individual of the risks and benefits of refusing
examination and treatment.
• The hospital MUST take all reasonable steps to secure the individual’s written consent to refusal of
further medical examination and treatment.
35
Notice and Record Keeping
• Hospitals are required to maintain all records related to persons transferred for a minimum of 5 years.
• Maintain the list of on-call physicians.
• Maintain a central log on each patient who comes to the DED to track the care provided.
36
Recipient hospital responsibilities:
• A hospital is required to report to CMS or the
State survey agency within 72 hours of the
occurrence when it suspects it may have
received an improperly transferred individual.
• Failure to report improper transfers may subject
the receiving hospital to termination of its
provider agreement.
37
Recipient hospital responsibilities:
A hospital that has specialized capabilities or
facilities (including, but not limited to, facilities such
as burn units, shock trauma units, neonatal
intensive case units, or, with respect to rural areas,
regional referral centers) may not refuse to accept
from a referring hospital an appropriate transfer if
the receiving hospital has the capacity to treat the
individual.
38
The patient’s visit to the ED should contain the
following to meet CMS expectations:
1. Central log entry with disposition2. Triage record
3. On-going vitals recorded
4. Oral history
5. Physical exam of affected systems
6. Physical exam of potentially affected systems and known chronic conditions
7. Any testing necessary to rule out the presence of a legally defined Emergency Medical Condition
8. Use of on-call personnel PRN to complete above
9. Use of on-call physician PRN to diagnose and stabilize patient
10. Resolution of abnormal findings or test results by normalization (serial values) or explanation of why they are not significant to the presentation
11. Discharge/transfer vitals12. Adequate documentation of all above
39
Who is the Enforcer?
CMSSanctions include:
• Termination of hospital’s provider agreement.
• Civil money penalties ($50,000 if over 100 beds, $25,000 if less than 100 beds) against both hospital and physician.
• Exclusion of physician.
• Malpractice suit.
• Physicians are not covered under their Malpractice insurance for a violation of EMTALA.
40
Suspected Violation? What to do?
• Contact your direct supervisor, and follow
normal event reporting protocol.
• Administration, in conjunction with corporate, will
development a corrective action plan and
complete a root cause analysis.
41
Example:
• A Texas hospital paid a $20,000 fine after a patient
left the ED without getting a medical screening exam
(“MSE”) because a desk clerk recommended he go
to his family physician.
• Takeaway: no matter how small an injury appears,
all patients seeking emergency care must get an
appropriate MSE.
42
Example:
• In Texas, a suicidal patient presented with underlying
hypotension. The hospital treated the psychiatric
condition and transferred the patient to a specialty
hospital, but they failed to fully treat the
hypotension. The hospital paid $20,000.
• Takeaway: when a patient has multiple conditions, the
hospital must stabilize each one within its capability.
43
OIG Example:
• An on-call surgeon at a large academic medical center in
Tennessee (AMC) refused to accept a patient. The
patient was transferred to another facility and died. The
AMC agreed to pay $45,000, and the physician was
personally fined $35,000.
• Takeaway: make sure physicians know they must accept
patients if the facility has the capacity and capability to
treat them.
44
On-Call Scenario
• On-call physician asked to come in to see an ED
patient, responds with instructions to admit or to run
various testing and that the on-call physician will see
the patient at a later time.
• EMTALA requires prompt response within a
"reasonable" time to be specified by the bylaws.
These times are not extended by necessary or
prudent testing or by admission. Delays will lead to
violations for failure to promptly evaluate or stabilize
the patient.
45
On-Call Scenario
• On-call physician asked to come in to see an ED patient, debates with ED physician over the
necessity of coming in.
• Once the request is made to come in, the duty attaches. In addition, EMTALA places the
decision power with the physician with eyes on
the patient. Response is not negotiable or debatable.
46
EMTALA Q/A
• When covering more than one hospital on-call, asking a patient be sent to the hospital where the on-call physician is currently seeing patients instead of going to the patient’s location.
• EMTALA requires all care to be rendered in the hospital where the patient presents. The only circumstances where the request to transfer would be valid would be if the needs of the patient could not be met in timely fashion where the patient presented, and the requested transfer would allow more timely intervention for patient safety and response of the on-call physician was not possible (i.e. currently involved in surgery). Thorough documentation would be important.
47
Interpretive Guidelines – Who
Must Take Call?
• CMS will consider all relevant factors,
including the number of physicians on
staff, other demands on these
physicians, the frequency with which
the hospital’s patients typically require
services of on-call physicians, and the
provisions made for situations in which
a physician specialty is not available.
48
“Simultaneously On-Call”
• On-call docs can be on-
call at more than one
institution.
• Must be a plan for when
the on-call physician is
not available.
49
Interpretive Guidelines
• “The best practice for hospitals, which offer
particular services to the public, should be
available through on-call coverage of the
ED.”
• CMS Phone Contact: Any specialty with a
significant presence on a medical staff,
offering services to the community,
available for inpatient care, will be
represented on the on-call schedule.
50
EMTALA Q/A
• When asked to come in to see an E.D. patient, declining
on the basis that the patient was previously discharged
from the physician’s practice for non-compliance, prior
litigation, or non-payment.
• While the patient has the right to decline the on-call
physician, the on-call physician does not have the right
under EMTALA to decline the patient. He/she may arrange
for someone else to present in his/her stead.
51
Transfer Acceptance Scenario #1
• ER attending physician receives a call from a small rural hospital wanting to transport a 50 yo
male with chest pain to your facility. The rural
hospital has done an EKG and performed blood work. ER attending denies the transport
suggesting that the patient be admitted to the rural hospital for observation. Rural hospital
does not have a cardiologist on staff.
• Is this an EMTALA violation?
52
Transfer Acceptance Scenario #1
• EMTALA Violation :
• The transferring hospital determines that the
patient requires further examination and
treatment in order to stabilize the emergency medical condition
• “A hospital with specialized capabilities may not
refuse to accept an appropriate transfer if patient
requires specialized capabilities and there is capacity and capability”.
YES
53
Transfer Acceptance Scenario #2
• 45 yo male with a subdural hematoma from
a fall. ED physician calls the regional
trauma center to transfer. Resident from
trauma facility refuses the transfer even
though hospital has NS coverage.
• Is this an EMTALA violation?
54
Transfer Acceptance Scenario #2
• EMTALA Violation :
• The transferring physician determines that the patient
requires further examination and treatment in order to
stabilize the emergency medical condition.
• “A hospital with specialized capabilities may not refuse to accept an appropriate transfer if patient
requires specialized capabilities and there is
capacity and capability”.
YES
55
Transfer Acceptance Scenario #3
• 35 yo female with ovarian torsion. Local
facility does not have GYN services. ED
physician called the referral hospital which
refused to accept the patient since they did
not participate in her insurance. Advised to
call other facilities which delayed ultimate
care.
• Is this an EMTALA violation?
56
Transfer Acceptance Scenario #3
• EMTALA Violation :
• “A hospital with specialized capabilities may not
refuse to accept an appropriate transfer if patient
requires specialized capabilities and there is capacity and capability”.
• Cannot inquire about financial status.
YES
57
Transfer Acceptance Scenario #4
• 85 yo male presents with a ruptured AAA.
Local hospital has no general or vascular surgery backup. Patient is unstable with
hypotension and tachycardia. ED physician
speaks to CV surgeon at referral hospital. Surgeon states patient is too “ill and unstable”
for transfer and refuses transfer. Patient expires 8 hours later after multiple attempts to
transfer fail.
• Is this an EMTALA violation?
58
Transfer Acceptance Scenario #4
• EMTALA Violation :
• When a hospital has exhausted all of its capabilities in
attempting to resolve the EMC, it must effect an appropriate
transfer of the individual (see Tag A-2409/C-2409).
• If an individual’s EMC has not been stabilized, prior to
transferring the individual to another hospital, the sending
hospital is required under EMTALA to pursue a transfer because
either:
– the individual requests the transfer; or
– the expected benefits of the transfer outweigh the increased
risks of the transfer.
YES
59
Frequent ED patient example…
• A frequent Flyer” patient was seen, treated and discharged from
the ED.
• Patient returned to the same ED within minutes of discharge with
different complaints and threats of self-harm, asking to be seen.
• The same ED doctor who was still on duty refused to see the
patient and went to lobby and told the patient to leave.
• Patient went to the parking lot and called 911 and reported intent
to kill himself, had a knife in his hand when police arrived.
• Police returned patient to ED registration and asked for a
psychiatric/medical evaluation and treatment on patient’s behalf.
• Doctor again came to lobby and told police she had seen this
patient earlier, and refused to see the patient again. Police took
patient to another ED in the same city and filed EMTALA complaint
with the state department of health.60
EMTALA Example (Medical Screening)
61
• Patient #1 stated she presented at the
hospital ED on 11/07/16 and asked if there
was a doctor who specialized in kidney
failure.
• Patient #1 stated she was told to go next
door to see a doctor as a walk-in as the ED is
only for emergencies.
References
1. Centers for Medicare and Medicaid (2005), Social Security
Act Section 1867 (42 USC 1395dd), Regulations: 42
CFR 489.24
2. State Operations Manual ,(Rev. 60, 07-16-10) :
Appendix V – Interpretive Guidelines –
Responsibilities of Medicare Participating
Hospitals in Emergency Cases
http://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/Downloads/som107ap_v_
emerg.pdf
62
Contact Us
www.QHR.com | (615) 371-7979
Shaheed Koury, MD, MBA, FACEP
Senior Vice President & Chief
Medical Officer
(615) 221-3510
