Transcript No Slide Title

The Revised EMTALA Rule:
What Looms on the Horizon?
Washington State Hospital Association
Association of Washington Public Hospital Districts
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Washington State Hospital Association
Association of Washington Public Hospital Districts
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Washington State Hospital Association
Association of Washington Public Hospital Districts
The Revised
EMTALA Rule:
What Looms on the Horizon?
Washington State Hospital Association
Association of Washington Public Hospital Districts
Presenters
Taya Briley,
Dick Goldsmith,
Director, Legal
Affairs and
Clinical Policy,
WSHA
Director, Legal
Services and Health
Policy, AWPHD
Barbara
Shickich,
Principal, Riddell
Williams, P.S.
Purpose of the Web Cast
• Provide a brief background on
EMTALA
• Describe the major changes in the
revised rule
• Offer some perspective on the rule
• Most importantly: hear what the rule
means (or might mean) to your facility
EMTALA Background
• Emergency Medical Treatment and
Active Labor Act of 1986 (EMTALA)
• Civil monetary penalties/revocation of
Medicare participation for hospitals and
physicians who, in an emergency care
context fail to comply with EMTALA
requirements
EMTALA Obligations
• Medical screening examination
• Stabilizing care
• Appropriate transfer
• Maintain on-call system
• Maintain central log of individuals who
come to emergency department
Revised EMTALA Rule
• Proposed changes May 9th 2002
• Final rule published September 9th 2003
• Final rule effective November 10th
2003
Centers for Medicare and
Medicaid Services Goals for Revision
• Recognize real world situations
• Clarify requirements
• Resolve conflicting court opinions
• Follow common sense
• NOT to weaken patient protections
The Final Rule
• Where EMTALA applies
• Exceptions to when EMTALA applies
• Medicare Conditions of Participation
• Registration process
• Ambulances
• National emergencies
• On-call roster
Where EMTALA Applies
• EMTALA obligations start when a
person “comes to the emergency
department”
• Definition differs depending on where
the person presents on hospital property
Where EMTALA Applies:
Dedicated Emergency Department
• EMTALA applies to an individual
presenting at a “dedicated emergency
department” and
– requests examination or treatment for a
medical condition or
– has such a request made
– also applies where a “prudent layperson”
would say the person needs examination or
treatment
Dedicated Emergency Department
(DED)
• “DED” is defined to be: On or off main
hospital campus and
– licensed by the state as an emergency
department or
– held out to the public as an emergency
department or place providing urgent care
without an appointment or
– 1/3 of outpatient visits during previous year
were for emergency medical conditions or
urgent care needs without an appointment
(implications for labor and delivery and
psychiatric departments)
Where EMTALA Applies:
On Campus
• On campus EMTALA does not apply to
departments other than DEDs unless
emergency services are requested
• Prudent layperson standard applies
• Hospital property does not include the
following facilities that participate in
Medicare separately from the hospital:
– physician offices
– rural health clinics
– skilled nursing facilities
• Does not apply to other non-medical services
Where EMTALA Applies:
Off Campus
• Off campus, determine if the definition
of “dedicated emergency department” is
met
• If EMTALA does not apply, the hospital
must have policies and procedures in
place to handle emergencies
Exceptions to When EMTALA Applies
• Inpatients
– EMTALA does not apply to a patient who
is admitted as an inpatient
• Outpatients
– Once a patient has begun a scheduled
outpatient procedure EMTALA does not
apply
Medicare Conditions of Participation
• Although EMTALA may not apply
Medicare Conditions of Participation
govern many cases instead
• Particularly true for inpatient and
outpatient circumstances
• Failure to comply with Conditions of
Participation may result in ineligibility
to participate in Medicare
• State laws still apply
Registration Process
• The normal ED patient registration
process may be followed as long as
patient care is not delayed
• Hospital may not seek prior
authorization for screening or
stabilization services until after medical
screening and initiating any other
treatment necessary to stabilize
condition
• Consultation with another physician is
allowed
Air or Ground Ambulances
• EMTALA does not apply to a hospital
owned ambulance if
– it is operated under community EMS
protocols that direct a patient to another
hospital or
– if the ambulance is operated at the direction
of a physician who is not employed/
affiliated with the hospital that owns the
ambulance
National Emergencies
• Hospitals in a national emergency area
will not be cited for transfers that would
otherwise violate EMTALA
• Does not address local emergencies
On-Call Roster
• CMS says not a change in prior policy
• Hospitals must maintain an on-call list
in a manner that best meets needs of the
hospital’s patients receiving required
EMTALA services
• Must be in accordance with resources
that are available to the hospital,
including the availability of on-call
physicians
Determining Adequate On-Call Coverage
• CMS will consider the following
factors:
– number of physicians on staff
– other demands on the physicians
– frequency with which hospital’s patients
typically require services of on-call
physicians
– provisions the hospital has made for
situations where a physician in a particular
specialty is not available or on-call
physician is unable to attend
“Gaps” In On-Call Services
• Hospital must have a policy in place to
respond where a specialty physician is
not available or cannot respond due to
circumstances beyond his/her control
• “Dual on-call”: policy must be in place
for emergency services to meet patient
needs if physicians are permitted:
– to schedule elective surgery when on-call
OR
– to be on-call at multiple hospitals
Responding to Call
• Physician can have mid-level
practitioner respond to call if it is
appropriate
• Emergency department physician must
agree
• Defer to judgement of emergency
department physician if there is a
disagreement about whether a particular
situation requires expertise of on-call
specialist
Select Call
• Physician may come to hospital to see
own patients on rounds or in response to
request without being considered on-call
• BUT: EMTALA violation if physician
responds to call for patients with whom
he/she has a doctor-patient relationship
while declining call from other patients,
including those without ability to pay
The Critique:
General Comments on the Rule
• American Hospital Association
• American College of Emergency
Physicians
• Consumer Groups
• EMTALA Legal Experts
Perspective on the Rule
• Good news for hospitals
– Clarifies CMS interpretations
– Narrows the scope of EMTALA obligations
Some Bad News
• Introduces dedicated emergency
department concept
• Creates ambiguity for on-call
requirements
• Defers guidance on psychiatric patients
and Medicare+Choice plans
• Presents potential problem with
“prudent layperson standard”
Flexibility Creates Uncertainty
• On-call requirements
– Ambiguity may weaken hospital ability to
provide on-call services
• Registration process
– Balance need for obtaining financial
information against risk of perception that
care was delayed
Flexibility Creates Uncertainty
Continued
• Role of non-physician providers
– Who is appropriate provider to conduct
medical screening?
– Balance more efficient use of staff against
risk of not identifying emergency condition
Compliance Challenges
• Satisfying on-call requirements
– Physician/hospital relationships at stake?
• Identifying dedicated emergency
departments
– Areas not previously considered to be
DEDs
More Compliance Challenges
• Monitoring admission of patients
– Assure admissions are made in good faith
• Assuring Medicare Conditions of
Participation are consistently met
– Consider how Conditions of Participation
apply in emergency context
EMTALA and the Medicare Bill
• House bill includes provisions
requiring:
– Medicare to pay for emergency services
– Notification of when EMTALA
investigations are closed
– Peer review in EMTALA cases that involve
termination from Medicare program
– The Secretary must establish an advisory
committee to look at implementation of
EMTALA
EMTALA Resources
• American Hospital Association
– www.hospitalconnect.com
• Health Law Resource Center
– www.medlaw.com
• Centers for Medicare and Medicaid
Services
– www.cms.hhs.gov
• American Health Lawyers Association
– www.healthlawyers.org
EMTALA Resources
• CMS Open Door Forum on EMTALA
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Thursday, October 2, 2003
2:00 PM Eastern / 11:00 AM Pacific
Call 1-800-837-1935 (TTY dial 711)
ID = 2787065
Recorded archive available October 6-9 by
calling 1-800-642-1687
Questions?
Washington State Hospital Association
Association of Washington Public Hospital Districts
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Association of Washington Public Hospital Districts