Emergency Medical Treatment and Active Labor Act (EMTALA) was enacted by Congress in 1986 as part of the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985. It was designed to prevent hospitals from refusing to treat patients or transferring them to charity/county hospitals due to inability to pay. It now has more far reaching requirements. The top two complaints included: treatment delay by managed care organization arrangements and failure to respond or delay by on-call physician.
EMTALA, better known at the federal “anti-dumping law,” requires emergency care to be provided to anyone who needs it, regardless of their ability to pay or insurance status. Under the law, all patients with similar medical conditions must be treated consistently. All patients with potential emergency conditions are to be provided a medical screening exam and stabilized. Medical Screening Exams (MSE) are performed by physicians and/or qualified medical personnel in conjunction with the attending physicians as defined by the Board of Directors. The medical screening exam CANNOT be delayed due to registration or obtaining financial information. The MSE is an exam which includes obtaining a history, performing a physical exam, performing appropriate diagnosis testing, consulting with the appropriate on call physicians/healthcare professional.
EMTALA applies when an individual “comes to the emergency department.” This is interpreted as those individuals on hospital property, not just the “four walls” of the emergency department.
Emergency medical condition is defined as a condition manifesting itself by acute symptoms that need immediate medical attention, including severe pain, psychiatric disturbance, substance abuse, and active labor. In the absence of medical attention, the patient and/or unborn child’s health could be jeopardized and might result in serious impairment to bodily functions or serous dysfunction to and organ or body part.
Under EMTALA a patient cannot be transferred unless he/she is stable and was provided a medical screening examination. Exceptions include patient written request or physician certification along with informed consent that the benefits of transfer outweigh the risks. Transfers must be done in accordance with hospital policy and documentation must reflect policy. The Transfer Policy can be found in the Administrative Policy/Procedure Manual.
On-call physicians have a duty to respond when called to assist with the medical screening exam and/or stabilization of the patient. If an on-call physician refuses to respond or fails to make a timely response and the patient is transferred as a result of this, the hospital is obligated to provide his/her name and address on the transfer form/records. A physician on-call at more than one hospital simultaneously, may not request that a patient be transferred to the second hospital for his/her convenience. Additionally, on-call physicians who, as part of their routine responsibilities, are charged with the duty to accept patients transferred from other facilities, may not refuse any unstable transfer as long as their hospital has the capability and capacity top provide treatment. An on-call physician cannot request that a patient be sent to his/her office for the medical screening exam and stabilization unless the on-call physician’s office has specialized equipment and capability that the transferring hospital does not have. The transferring physician must certify that the medical benefits of the transfer outweigh the risk and it is in the best medical interest of the patient. Each hospital is responsible for maintaining a current on-call list of physicians. This list must be maintained for a period of five years.
Penalties under EMTALA include:
q fines of $50,000 per violation for a given hospital and/or physician- which is NOT covered by insurance,
q possible loss of medicare certification by the hospital and/or physician,
q private civil suit by the patient for personal injury, and/or
q private civil suit by the receiving hospital for financial loss.
Note: No injury to the patient need occur for a penalty to be imposed. Additionally, poor patient outcome or medical malpractice does not necessarily signal an EMTALA violation.
Each hospital is mandated to maintain and retain registration logs in the emergency department, labor/delivery, and other point of entry areas where a patient might be provided a medical screening exam and stabilized. Additionally signs are posted to inform the public about this law. The Administration Manual has a specific policy addressing EMTALA.
What can you do to protect yourself?
q Defer discussions about patient’s ability to pay for treatment until the medical screening exam has been completed and treatment necessary to stabilize the patient has been provided.
q Respond timely (per Medical Staff Bylaws) to calls when you are the designated “on-call” physician.
q Ensure patients with emergency medical conditions are transferred only after they have been stabilized, patient has provided written request, or there is a physician. The emergency medical condition is not limited to those situations in the emergency department.
q Carefully document reasons for transfer, informed consent, and the risks/benefits on the transfer consent form.
q Work cooperatively with other facilities in arranging transfers and document receiving physician and facility.
q If you become aware of a patient intending to leave prior to a screening examination, inform the individual of the risks and obtain signature for an informed-refusal/AMA form.
This is a very complicated subject with very serious consequences for everyone. If you have questions or concerns, believe there is an internal EMTALA violation or that the hospital received a patient as a result of another facility’s violation, contact Risk Management.