EMTALA: Maintain Compliance

Before 1986, many uninsured or underinsured emergency department (ED) patients were transferred from private hospitals to public hospital EDs without appropriate screening and stabilization. Occurring frequently in large metropolitan areas such as Chicago, New York, and Dallas, this practice became the subject of enormous concern and finally garnered the attention of the federal government.

In 1986, Congress enacted the Emergency Medical Treatment and Active Labor Act (EMTALA) as part of the Consolidated Omnibus Budget Reconciliation Act (COBRA). EMTALA was established to guarantee that all patients have access to emergency care, regardless of their ability to pay. EMTALA was also intended to prevent “patient dumping,” the act of transferring an uninsured patient to another facility exclusively for financial reasons without regard for that patient’s medical condition as described above.

Studies have shown that EMTALA violations happen at a rate of 4-5% annually and majority of violations occur in high-volume emergency departments. However, one EMTALA violation can have a considerable financial impact on facilities and providers. Hospitals violating EMTALA are subject to civil penalties of $64,618 to $129,2332 per violation, lawsuits for damages, and/or exclusion from Medicare. (42 U.S.C. § 1395dd(d); 42 C.F.R. § 1003.103(e); 45 C.F.R. § 102.3). Physicians, including on-call physicians who violate EMTALA, may be subject to a civil penalty of $129,233. Penalties depend on the number of hospital beds and may be adjusted periodically.

There are three major requirements to keep in mind when evaluating your compliance with EMTALA regulations.

  1. Medical Screening Exams (MSE) without delay
  2. Patient Stabilization and Treatment without delay
  3. Hospitals with specialized services are required to accept patients needing those services

A Medical Screening Examination (MSE) must be completed and documented on every patient presenting to the emergency department for medical care. This requirement applies not only to the hospital’s ED but also to the hospital’s entire property and campus within 250 yards. Although there is no guidance as to what constitutes a medical screening or who is responsible for the MSE other than “qualified medical personnel,” it is important to know that the MSE should be standardized and not delayed.

After the MSE, if it is determined the patient has an “Emergency Medical Condition,” the hospital is required to provide stabilization and treatment. This includes on-call physicians needed to assist in the stabilization and treatment of the patient. As noted previously, the MSE should be standardized utilizing the same medical screening processes/protocols and stabilizing treatments for all patients with comparable signs and symptoms regardless of their ability to pay, insurance coverage, or legal status. Note: hospitals must have an on-call list characteristic of the typical services provided at the hospital and maintain that list for five years.

Once a patient is stabilized, the receiving hospital cannot refuse to accept the patient if the hospital has the capacity to provide care. Additionally, if the patient is unstable yet the transferring hospital has done everything possible to stabilize the patient and the benefits of transfer outweigh the risk, the patient may be transferred and as noted above, the receiving facility must accept the transfer.

The Department of Health and Human Services (HHS) announced in January of this year that the Centers for Medicare & Medicaid Services (CMS) will begin a comprehensive plan related to the Emergency Medical Treatment and Labor Act (EMTALA). The goals of this plan are: (1) to educate the public about their rights related to emergency medical care, and (2) to support hospitals that are subject to EMTALA in meeting their obligations. This comprehensive plan will:

  • Enhance CMS’s website with resources to help individuals understand their rights under EMTALA and the process for submitting a complaint if they are denied emergency medical care;
  • Develop hospital and provider association(s) partnerships to disseminate training materials on providers’ obligations under EMTALA;
  • Convene hospital and provider associations to discuss best practices and challenges in ensuring compliance with EMTALA; and
  • Establish a dedicated team of HHS experts who will increase HHS’s capacity to support What Hospitals Can Do Now to Prepare

According to John Berry, Specialist Principal Consultant, CMS at Joint Commission Resources, one of the areas where healthcare facilities are most often found lacking in a CMS survey is EMTALA. Berry noted since compliance with EMTALA is complaint-driven, it is not routinely surveyed by CMS or Accreditation Organizations as part of initial or re-accreditation surveys; it is up to the organization to ensure it complies. Given the new focus by CMS to better educate the public regarding their rights related to emergency care, hospitals are likely to see an increase in complaints and investigations into those complaints. To minimize the possibility of an EMTALA violation, hospitals should:

  • Review Federal Regulation- § 489.24 Special responsibilities of Medicare hospitals in emergency cases
  • Ensure all relevant personnel are educated on the requirements of EMTALA
  • Ensure training on EMTALA is provided at orientation and annually
  • Develop, review/revise EMTALA-related policies and procedures and provide comprehensive education for staff
  • Ensure comprehensive ED patient log contains all necessary information concerning disposition (admission, transfer, discharge, AMA, refusal of treatment)
  • Ensure EMTALA signage is visible and appropriate in language and location
  • Review the provider on-call list to ensure it includes appropriate information
  • Evaluate the ED transfer log and physician certifications
  • Audit medical records of patients transferred, left AMA, LWBS, or had a long arrival to MSE time and provide education when concerns are identified
  • Regularly conduct mock EMTALA surveys, including record reviews and interviews

EMTALA Resources and References:

For more information on maintaining EMTALA compliance, reach out to our expert Carla Wilber, DNP, RN, NE-BS, CATC, CPHQ.