2Emergency Medical Treatment and Active Labor Act Sometimes called “COBRA”Consolidated Omnibus Budget Reconciliation ActPart of this voluminous, multifaceted act was EMTALA
3What is EMTALA?Federal statute (Congressional law) passed in 1986 in response to concerns about patient “dumping”Found in the United States CodeLaw enforced by CMS (Center for Medicare/Medicaid Services) and OIG (Office of the Inspector General)CMS (then HCFA) published regulations in 1994 (with some subsequent revisions)Found in the Code of Federal Regulations
4CMS also published “interpretive guidelines” in 1995 Last revision in 2004Guidelines are used by surveyors in review of EMTALA concernsFound in Medicare State Operations Manual
5Why should we worry about EMTALA? CMS can terminate the Hospital’s Medicare provider agreement (42 CFR )“The Big Stick”The OIG has authority to exclude “responsible physicians” from participation in Medicare, Medicaid and all federal health programs for EMTALA violations (42 CFR )The OIG can impose Civil Money Penalties (CMP) on both the hospital or CAH and the responsible physician (42 CFR 1003)up to $50,000 per violation (100+ beds)$50,000 per violation per physicianPatients may bring civil actions for damages
6OverviewA person who comes to the emergency department for examination or treatment for a medical condition must receive a medical screening examination to determine whether an emergency medical condition exists
7If there is an emergency medical condition, the hospital must provide either - Further medical examination and treatment to stabilize the medical condition, orAppropriate transfer
8The “Magic Words” “Comes to the Emergency Department” “Emergency Medical Condition”“Medical Screening Examination”“Stabilize”“Transfer”
9“Comes to the Emergency Department” The individual is on hospital propertyNot just the ED itself!Includes all of main campus, sidewalks, driveways and parking lotsIncludes ambulances that have come on the propertyUnless directed elsewhere by EMS
10“Campus”… and the “250 yard rule” The physical area immediately adjacent to the provider's main buildings, other areas and structures that are not strictly contiguous to the main buildings but are located within 250 yards of the main buildings, and any other areas determined on an individual case basis, by the CMS regional office, to be part of the provider's campus.
11“Campus”… and the “250 yard rule” Only “hospital owned or operated” areas within the 250-yard radius are subject to EMTALAE.g., does not include public streets that happen to be inside the radiusUWMC has some combined (with UW) areas in this radius—are they included?CMS probably would say “yes” if a member of the public would reasonably assume that the area is hospital operated.
12“Emergency Medical Condition” Acute symptoms (including severe pain, psychiatric disturbances and/or symptoms of substance abuse)
13“Emergency Medical Condition” Symptoms severe enough that without immediate medical attention, one could reasonably expectSerious impairment to bodily functionsSerious dysfunction of any bodily organ or partOther serious jeopardy to health of patient (or unborn child)
14“Emergency Medical Condition” Emergency medical condition in a pregnant woman who is having contractionsInadequate time to effect a safe transfer to another hospital before delivery; orTransfer may pose a threat to the health or safety of the woman or the unborn child
15“Emergency Medical Condition” If the “reasonably prudent layperson” would think that the symptoms being exhibited might be an emergency medical condition, then it must be considered one unless/until it is ruled out.Note: EMTALA does not apply to outpatients who are receiving patient caree.g., a clinic patient who develops an emergency during the patient care portion of their visit
16“Medical Screening Examination” Process required to reach with reasonable clinical confidence the point at which it can be determined whether a medical emergency (i.e., “emergency medical condition”) existsTRIAGE DOES NOT QUALIFY AS A MEDICAL SCREENING EXAMINATION!!
17“Medical Screening Examination” MSE is to be conducted by “qualified medical personnel”“Medical and nursing personnel qualified in emergency care to meet the written emergency procedures and needs anticipated by the facility”Personnel are determined to be qualified by hospital bylaws or rules and regulations
18“Medical Screening Examination” Depending on presenting symptoms, MSE may be“A simple process involving only a brief history and physical examination” ORMore complex process including ancillary studies and procedures “routinely available to the emergency department”Including, but not limited to lumbar punctures, clinical lab tests, CT scans, other diagnostic tests and procedures
19Pre-authorization Not Allowed “It is not appropriate for a hospital to request or a health plan to require prior authorization before the patient has received a medical screening exam to determine the presence or absence of an emergency medical condition or until an existing emergency medical condition has been stabilized.”
20Refusal Based on Managed Care Not Allowed “A hospital may not refuse to screen an enrollee of a managed care plan because the plan refuses to authorize treatment or to pay for such screening and treatment.”
21“Stabilize”Medical treatment of the condition necessary to assure, within reasonable medical probability, thatNo material deterioration of the condition is likely to result from or occur during the transfer; orChild and placenta have been delivered
22“Transfer”Movement (including discharge) outside the hospital's facilitiesat the direction of any person employed by or affiliated or associated, directly or indirectly, with the hospital; orupon a documented, informed request by the patient
23“Stable for Transfer”Treating physician has determined, within reasonable clinical confidence, that the patient is expected to reach the receiving facility with no material deterioration in medical conditionTreating physician reasonably believes receiving facility has the capability to manage the patient’s medical condition and any reasonably foreseeable complications
24Requirement to Transfer “When a hospital has exhausted all of its capabilities in attempting to remove the emergency medical condition, it must effect an appropriate transfer of the individual.”
25“Stable for Discharge” Within reasonable clinical confidence, the patient has reached the point where continued care (including diagnostic work-up and/or treatment) could be reasonably performed as an outpatient, or later as an inpatientPatient must be given a plan for appropriate follow-up care with discharge instructions
26Certification for Transfer Based upon the information available at the time of transfer, the medical benefits of treatment reasonably expected at the receiving facility outweigh the risks of being transferredCertification must contain summary of the risks and benefits upon which it is based
27Certification for Transfer Physician must sign, orQualified medical person may sign after consulting physician who agrees with the certificationAgreeing physician must subsequently countersign
28RefusalsPatient may refuse further medical examination and treatment, or transferHospital must inform patient or patient’s representative of the risks and benefits of examination and treatment or transfer
29Documentation Requirements Medical record must containdescription of examination, treatment, or both; or description of the proposed transfer; andthat the person has been informed of the risks and benefits of examination, treatment, or transfer; andperson’s reasons for refusal.Hospital must take all reasonable steps to secure written informed refusal.
30Recipient Hospital Obligations This obligation is a bigger practical issue for UWMC than transfer obligationsUWMC may not refuse to accept from a referring hospital within the boundaries of the United States an appropriate transfer of a patient who requires our specialized capabilities or facilities if we have the capacity to treat the patient.
31More “magic words”“Specialized capabilities”: Including, but not limited to, facilities such as burn units, shock-trauma units, neonatal intensive care unitsWould encompass UWMC higher-level (tertiary/quaternary) services“Capacity”: Factors include number of patients occupying a specialized unit, number of staff on duty, or available equipment, AND ALSO whatever a hospital customarily does to accommodate patients in excess of its occupancy limitse.g., moving patients to other units, calling in additional staff, borrowing equipment from other facilities
32More “magic words” “Appropriate transfer”: Patient must be Stable for transfer ORBenefit of transfer outweighs risk ORPatient requested transfer ANDPatient must require our specialized capabilities (or transferring hospital lacks capacity) ANDUWMC must agree to the transfer ANDRequired documentation must accompany patientMedical recordTransfer certification
33Does EMTALA apply to the transfer? If the patient is a “legitimate” inpatient at the transferring hospital, EMTALA does not applyConcerns about a “sham admission” (i.e., an attempt to circumvent EMTALA) would arise if the transferring hospital sends us the patient within a few hours of admission (unless the patient has deteriorated in that time frame)
34When in doubt… Determine if we have already “accepted” the transfer Ideally there will be physician-to-physician communication between UWMC and the transferring hospitalThe law does not require this, but please try to facilitate if this communication has not occurredUWMC should accept a “questionable” transfer and work out the potential reporting obligations later
35Posting Requirements EMTALA rights must be posted conspicuously in emergency department or where likely to be noticed by all individuals entering emergency department, andfor those waiting for examination and treatment in areas other than traditional emergency departments (entrance, admitting area, waiting room, treatment area)
36On-Call ListEmergency department must be prospectively aware of which physicians, including specialists and subspecialists, are available to patientsIf a hospital offers a service to the public, the service should be available through on-call coverage of the emergency department
37Central LogFor all patients, including active labor patients or other unstable patients who entered “by way of” the ED, even if later transferred from area other than the ED.Must include whether patient refused treatment, was refused treatment, was transferred, admitted and treated, stabilized and transferred, or discharged.Need not be in log format, but all information must be easily retrievable.
38Reporting Requirements Hospital must report to CMS or the State survey agency (DOH) within 72 hours if it has reason to believe it may have received a patient transferred in an unstable emergency medical condition from another hospital in violation of EMTALA requirements.
39EMTALA scenarios to watch for 1. Other hospital contacts us to try to transfer patient. After discussing with our Resident/Attending/On-call physician, we elect not to accept the transfer. Patient later shows up in our ED requiring emergent treatment. Possibly without paperwork.2. Patient presents in our ED and mentions that they received treatment at another hospital's ED immediately prior to coming to UWMC.3. Other facility goes to great lengths to transfer patient to UWMC ED, possibly against our advice. Patient arrives in unorthodox fashion (such as being driven interstate by private vehicle), possibly in unstable condition. It is not clear if patient's condition was stabilized by other facility.
40EMTALA red flags to watch for Any patient who shows up to our ED who has already been seen at another Emergency Room for the same condition with any of the following:No paperwork (labs, transfer, H & P, etc...); No arrangement or agreement on our part to accept the transfer;Transfer occurred against our recommendations;Patient or family member drove themselves from the other ED to our ED;Patient's condition not stable for transfer from previous facility;Patient's condition could arguably have been handled by the other hospital's on-call physician but that physician did not personally see the patient.
42What if I suspect an EMTALA violation related to a transfer from another hospital? Please enter information in PSN (Patient Safety Net)Please notify the ED nurse manager, ED Medical Director, or Compliance OfficeRob Brown,
43What about patients who are told to come to UWMC ED for follow-up care? The patient should be screened to rule out an emergency medical condition just as with any ED patientIf an EMC is ruled out, the patient may be dischargedOutside EMTALA and overall charity care obligations, UWMC (e.g., orthopedic clinics) has no duty to accept new patientsHowever, if the patient is given specific instruction to follow up with a UWMC clinic without the caveat that the clinic may not be able to take them on as a new patient, the obligation to treat the patient in follow-up may be created