Transcript EMTALA “101” for UWMC ED Staff Emergency Medical Treatment and Active Labor Act  Sometimes called “COBRA” –  Consolidated Omnibus Budget Reconciliation Act Part of this voluminous,

EMTALA “101” for UWMC ED
Staff
Emergency Medical Treatment
and Active Labor Act

Sometimes called “COBRA”
–

Consolidated Omnibus Budget Reconciliation Act
Part of this voluminous, multifaceted act was
EMTALA
What is EMTALA?
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Federal statute (Congressional law) passed in 1986
in response to concerns about patient “dumping”
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Found in the United States Code
Law enforced by CMS (Center for
Medicare/Medicaid Services) and OIG (Office of the
Inspector General)
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CMS (then HCFA) published regulations in 1994 (with some
subsequent revisions)

Found in the Code of Federal Regulations
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CMS also published “interpretive guidelines”
in 1995
Last revision in 2004
Guidelines are used by surveyors in review
of EMTALA concerns
Found in Medicare State Operations Manual
Why should we worry about EMTALA?
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CMS can terminate the Hospital’s Medicare provider agreement
(42 CFR 489.53)
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The OIG has authority to exclude “responsible physicians” from
participation in Medicare, Medicaid and all federal health
programs for EMTALA violations (42 CFR 1003.105)
The OIG can impose Civil Money Penalties (CMP) on both the
hospital or CAH and the responsible physician (42 CFR 1003)
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“The Big Stick”
up to $50,000 per violation (100+ beds)
$50,000 per violation per physician
Patients may bring civil actions for damages
Overview
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A 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
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If there is an emergency medical condition,
the hospital must provide either –
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Further medical examination and treatment to
stabilize the medical condition, or
Appropriate transfer
The “Magic Words”
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“Comes to the Emergency Department”
“Emergency Medical Condition”
“Medical Screening Examination”
“Stabilize”
“Transfer”
“Comes to the Emergency
Department”
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The individual is on hospital property
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Not just the ED itself!
Includes all of main campus, sidewalks,
driveways and parking lots
Includes ambulances that have come on the
property
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Unless directed elsewhere by EMS
“Campus”… and the “250 yard rule”
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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.
“Campus”… and the “250 yard rule”
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Only “hospital owned or operated” areas within the
250-yard radius are subject to EMTALA
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E.g., does not include public streets that happen to be
inside the radius
UWMC has some combined (with UW) areas in this
radius—are they included?
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CMS probably would say “yes” if a member of the public
would reasonably assume that the area is hospital
operated.
“Emergency Medical Condition”
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Acute symptoms (including severe pain,
psychiatric disturbances and/or symptoms of
substance abuse)
“Emergency Medical Condition”
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Symptoms severe enough that without
immediate medical attention, one could
reasonably expect
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Serious impairment to bodily functions
Serious dysfunction of any bodily organ or part
Other serious jeopardy to health of patient
(or unborn child)
“Emergency Medical Condition”
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Emergency medical condition in a pregnant
woman who is having contractions
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Inadequate time to effect a safe transfer to
another hospital before delivery; or
Transfer may pose a threat to the health or safety
of the woman or the unborn child
“Emergency Medical Condition”
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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.
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Note: EMTALA does not apply to outpatients who
are receiving patient care
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e.g., a clinic patient who develops an emergency during
the patient care portion of their visit
“Medical Screening Examination”
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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”) exists
TRIAGE DOES NOT QUALIFY AS A
MEDICAL SCREENING EXAMINATION!!
“Medical Screening Examination”
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MSE is to be conducted by “qualified medical
personnel”
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“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
“Medical Screening Examination”
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Depending on presenting symptoms, MSE
may be
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“A simple process involving only a brief history
and physical examination” OR
More complex process including ancillary studies
and procedures “routinely available to the
emergency department”
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Including, but not limited to lumbar punctures, clinical lab
tests, CT scans, other diagnostic tests and procedures
Pre-authorization Not Allowed
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“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.”
Refusal Based on Managed Care
Not Allowed
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“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.”
“Stabilize”
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Medical treatment of the condition necessary
to assure, within reasonable medical
probability, that
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No material deterioration of the condition is likely
to result from or occur during the transfer; or
Child and placenta have been delivered
“Transfer”
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Movement (including discharge) outside the
hospital's facilities
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at the direction of any person employed by or
affiliated or associated, directly or indirectly, with
the hospital; or
upon a documented, informed request by the
patient
“Stable for Transfer”
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Treating physician has determined, within
reasonable clinical confidence, that the
patient is expected to reach the receiving
facility with no material deterioration in
medical condition
Treating physician reasonably believes
receiving facility has the capability to manage
the patient’s medical condition and any
reasonably foreseeable complications
Requirement to Transfer
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“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.”
“Stable for Discharge”
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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
inpatient
Patient must be given a plan for appropriate
follow-up care with discharge instructions
Certification for Transfer
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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
transferred
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Certification must contain summary of the risks
and benefits upon which it is based
Certification for Transfer
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Physician must sign, or
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Qualified medical person may sign after
consulting physician who agrees with the
certification
Agreeing physician must subsequently
countersign
Refusals
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Patient may refuse further medical
examination and treatment, or transfer
Hospital must inform patient or patient’s
representative of the risks and benefits of
examination and treatment or transfer
Documentation Requirements
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Medical record must contain
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description of examination, treatment, or both; or
description of the proposed transfer; and
that the person has been informed of the risks
and benefits of examination, treatment, or
transfer; and
person’s reasons for refusal.
Hospital must take all reasonable steps to
secure written informed refusal.
Recipient Hospital Obligations
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This obligation is a bigger practical issue for
UWMC than transfer obligations
UWMC 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.
More “magic words”
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“Specialized capabilities”: Including, but not
limited to, facilities such as burn units, shock-trauma
units, neonatal intensive care units
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Would 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 limits
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e.g., moving patients to other units, calling in additional
staff, borrowing equipment from other facilities
More “magic words”
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“Appropriate transfer”: Patient must be
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Stable for transfer OR
Benefit of transfer outweighs risk OR
Patient requested transfer AND
Patient must require our specialized capabilities
(or transferring hospital lacks capacity) AND
UWMC must agree to the transfer AND
Required documentation must accompany patient
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Medical record
Transfer certification
Does EMTALA apply to the transfer?
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If the patient is a “legitimate” inpatient at the
transferring hospital, EMTALA does not apply
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Concerns 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)
When in doubt…
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Determine if we have already “accepted” the
transfer
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Ideally there will be physician-to-physician
communication between UWMC and the
transferring hospital
The law does not require this, but please try to
facilitate if this communication has not occurred
UWMC should accept a “questionable”
transfer and work out the potential reporting
obligations later
Posting Requirements
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EMTALA rights must be posted
conspicuously
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in emergency department or where likely to be
noticed by all individuals entering emergency
department, and
for those waiting for examination and treatment in
areas other than traditional emergency
departments (entrance, admitting area, waiting
room, treatment area)
On-Call List
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Emergency department must be
prospectively aware of which physicians,
including specialists and subspecialists, are
available to patients
If a hospital offers a service to the public, the
service should be available through on-call
coverage of the emergency department
Central Log
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For 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.
Reporting Requirements
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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.
EMTALA 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.
EMTALA 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.
EMTALA “FAQs”
What if I suspect an EMTALA violation
related to a transfer from another
hospital?
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Please enter information in PSN (Patient
Safety Net)
Please notify the ED nurse manager, ED
Medical Director, or Compliance Office
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Rob Brown, 598-4342
What about patients who are told to
come to UWMC ED for follow-up care?
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The patient should be screened to rule out an
emergency medical condition just as with any ED
patient
If an EMC is ruled out, the patient may be
discharged
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Outside EMTALA and overall charity care obligations,
UWMC (e.g., orthopedic clinics) has no duty to accept new
patients
However, 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