1. Emergency Medical Treatment and Labor Act (EMTALA) “New and Improved…plus stuff that’s not true.”
David Wright
Centers for Medicare and Medicaid Services (CMS)
Dallas Regional Office

2. Civil Liability versus Administrative Enforcement
Two Year statute of Limitations on Civil Cases alleging EMTALA Violation
CMS not involved, complainant not required to file complaint or have substantiated violation

3. EMTALA-Related Requirements
EMTALA Compliance Plan
Reporting Requirement
Signage
Medical Records Requirement
On-Call Physician List
Central Log

4. Reporting Requirement
Report to CMS or the state any time you have reason to believe the hospital received an individual who has been transferred in an unstable emergency medical condition from another hospital, in violation of the transfer requirements (489.24(d)).

5. Signage
It’s the law!
If you have a Medical Emergency or are in labor, you have the right to receive, within the capabilities and capacity of this hospital’s staff and facilities:
An Appropriate medical screening examination.
Necessary stabilizing treatment (including treatment for an unborn child) and, if necessary, an appropriate transfer to another facility.
Even if you cannot pay or do not have medical insurance or you are not entitled to Medicare or Medicaid.
This hospital does / does not participate in Medicaid.

6. Medical Records Retention
The hospital must maintain medical and other records related to individuals transferred to or from the hospital for a period of five years from the date of the transfer.

7. On-Call Physicians
Ensure ED is prospectively aware of which physicians, including specialists and sub-specialists are available to provide treatment necessary to stabilize individuals with emergency medical conditions.
Hospital must determine and enforce response times.
Physician must come in, cannot refer patient with emergency medical condition to private physician’s office.

8. On-Call Continued
Hospital Discretion, Simultaneous call, Elective Surgery
Still must provide for emergency services if physician unavailable due to elective surgery or simultaneous call
If on-call chooses to send non-physician practitioner, treating physician may still request on-call present in person.

9. Central Log
To track the care provided to each individual who comes to the hospital seeking care for an emergency medical condition, including whether the individual refused treatment, was refused treatment, admitted, treated, stabilized, transferred or discharged.

10. EMTALA Requirements Screening Stabilizing Treatment
Delay in examination or treatment
Appropriate Transfer
Recipient Hospital Responsibilities

11. Screening Determine presence/absence of emergency medical condition.
Performed by Qualified Medical Personnel.
EMTALA applies until patient stabilized or determination that there is no emergency medical condition.

12. Screening Cont’d
Present to Dedicated ED (Licensed, Held Out, 1/3 Presentations-calendar year) Request for Medical Treatment only. Everyone must be screened.
Non-Dedicated ED-Request for Emergency Medical Treatment only (Prudent Layperson standard)
Eliminates application to non-emergency off-campus sites.
Parking of EMS patients. Must still be assessed upon presentation

13. Never say never…
FAMILY LAWYER: HOSPITAL WORKER STEPPED OVER DEAD PATIENT DAYS BEFORE BODY WAS DISCOVERED. The Los Angeles Times (10/24, Dolan) reports on allegations that a hospital employee in San Francisco saw the body of a patient lying in an “emergency stairwell” and stepped over it days before the fatality was discovered. Haig Harris, an attorney representing the deceased patient’s family, says he was informed that the hospital employee saw the body of Lynne Spalding, 57 and reported it to a nurse, though it is unclear it took days for anyone to take action.

14. Stabilizing Treatment
Within capability and capacity of hospital, must ensure that:
the Emergency Medical Condition is removed, or
the patient is Stable for Discharge

15. Stabilizing Treatment
EMTALA obligation ends when patient admitted as inpatient, even if not stabilized.
Expectation of overnight stay.

16. Delay in Examination or Treatment
Hospital may not delay providing an appropriate medical screening examination in order to inquire about the individual’s method of payment or insurance status.

17. Delay Cont’d
Prior Authorization explicitly prohibited until after screening and initiation of stabilizing treatment
Reasonable registration, including insurance information, allowed.

18. Reason for Transfer
Patient request (in writing, with risk / benefit understanding).
Physician certification that benefits outweigh the risks.

19. Appropriate Transfer
Transferring hospital minimizes risks (within capability and capacity).
Receiving facility agrees to accept.
Transferring hospital sends all medical records.
Transfer effectuated with appropriate personnel and transportation.

20. Recipient Hospital Responsibilities
Participating hospitals with specialized capabilities may not refuse a request for an appropriate transfer of an individual requiring that capability if the facility has the capacity to treat the individual.

21. Recipient Hosp Resp Cont’d
Capability or Capacity only reason for refusal of transfer request under EMTALA
This requirement applies to any participating hospital with specialized capabilities, regardless of whether the hospital has a dedicated emergency department. (Effective, October 1, 2006)

22. EMTALA Waiver
72 Hours after issuance of waiver and activation of Hospital’s disaster protocol
Allows for otherwise inappropriate transfers due to circumstances arising out of emergency
Allows for screenings at alternate locations per State emergency plan
Evaluations still rest on capability and capacity

23. Regulatory Changes (OPPS ’09)
Continued non-application to unstabilized inpatients
Community Call
Indefinite Pandemic Flu Waiver

24. Recent EMTALA Issues
False Labor-Mid-wives, and QMPs may determine (effective October 1, 2006)
On-call refusal to come in / refusal to accept transfer
Triage vs. Screening (or “Screening Out”)
Coercion
250-Yard Rule
Diversion/Parking of EMS Patients
Helipads and Helicopter Transfers
Hospital-Owned and Operated Ambulances
Declared Emergency

25. CMS Review Procedures Possible Outcomes: No violation
Past Violation, No termination
Violation, Immediate and Serious Threat
Violation, No Immediate and Serious Threat
All investigations referred to QIO prior to finding of violation (MMA)

26. EMTALA Penalties CMS: Medicare Termination
DHHS Office of the Inspector General:
Hospital
CMP of $50,000 per violation for hospital ($25,000 if less than 100 Beds)
Physician
CMP of $50,000 per violation
Exclusion from Medicare and Medicaid programs

27. Three Keys to Compliance:
Consistency
Complaint system
Knowledge

28. 18/12

29. CMS EMTALA Websites General EMTALA Information
CMPs Imposed by the Office of the Inspector General

30. EMTALA Contacts David Wright PH: (214) 767-6426/ FAX: (214) 767-0270
Dodjie Guioa
PH: (214) /Fax: (214)
Dorsey Sadongei
PH: (214) /Fax: (214)
Sergio Mora
PH: (214) /Fax: (214)