Ask A Compliance Officer: EMTALA Q&A with Dr. CJ Wolf

Recently we held a webinar titled “EMTALA Mistakes You Should Never Make,” where we had a vibrant Q&A following the presentation. Because we didn’t have time to answer all of the questions during the webinar, I went through and answered some of the more interesting questions from the audience. If you have additional questions around EMTALA, be sure to leave them in the Comments section below.

Thanks again to all who attended. See you next time, CJ.

Question From M. Dhillon:

Is a patient MSE'd if he/she has been triaged by a first clinical rep but made to wait to see the Doctor? Can patients' Insurance Coverage info be asked while they are still waiting to be seen by a Doc? This seems to be most confusing for all ER Workers - clinical and non-clinical. When is it appropriate to ask and gather this info?

Answer:

The Final Rule shares a response to a question similar to yours about triaging: "Triaging is not equivalent to a medical screening examination. Triaging merely determines the 'order' in which patients will be seen, not the presence or absence of an emergency medical condition. If the medical screening examination is appropriate and does not reveal an emergency medical condition, the hospital has no further obligation under §489.24.

The decision to take vital signs may be required by the qualified medical professional or the hospital's emergency department's policies and procedures, or both. Vital signs are indicators of a patient's level of wellness and are valuable parameters to assist health professionals in making medical decisions concerning a patient's health needs. The patient's medical condition and the discretion of the practitioner will determine the need for monitoring of vital signs.

We do not believe the taking of a patient’s vital signs is required for every presentment to a hospital’s dedicated emergency department. As we have stated above, we expect that, in most cases in which a request is made for medical care that clearly is unlikely to involve an emergency medical condition, an individual’s statement that he or she is not seeking emergency care, together with brief questioning by qualified medical personnel, would be sufficient to establish that there is no emergency medical condition and the hospital’s EMTALA obligation would thereby be satisfied."

Question From M. Dhillon:

What about the opposite of Anti-dumping? Who should this refusal to accept transferring patient by the recipient hospital be reported to - CMS?

Answer:

I would suggest reporting it to CMS or the State survey agency.

Question From Z. Hamilton:

Is there a balance regarding not exposing a patient to financial duress vis a vis their non-coverages being accepted, even in emergencies? Or is this a separate consideration?

Answer:

In this context, the key to maintaining EMTALA compliance is to ensure that the MSE and stabilization of any EMC is not delayed due to these considerations.

Question From N. Hammond:

Are there required elements of MSE by EMTALA regulations (e.g., log entry with disposition, triage record, etc.)?

Answer:

There are not published required elements of an MSE by EMTALA regulations.

Question From T. LaPlante:

Does the patient have to present to the ED specifically, or can they be anywhere on our campus?

Answer:

Your question brings up the issue of the so-called "250-yard" rule. One of the best explanations of the 250-yard rule is the following by Honigman. "CMS states that EMTALA does not apply elsewhere on on-campus hospital property other than a dedicated emergency department unless an examination and treatment is requested for what may be an emergency medical condition. Thus, EMTALA applies to a person who has presented on hospital property, other than a dedicated emergency department, and requests examination or treatment for what may be an emergency medical condition or such a request has been made on his or her behalf. In addition, in the absence of a specific request, EMTALA will also apply if a prudent layperson observer would believe, based on the person’s appearance or behavior, that the individual needs emergency examination or treatment. For the purpose of determining whether EMTALA obligations are triggered, hospital property continues to be defined by the 250-yard test (i.e., within 250 yards of the main hospital building) for describing the hospital-campus (including parking lots, sidewalks and driveways). CMS has removed the specific language describing the 250-yard test from the final rule, but incorporates it by reference to 42 CFR 413.65(b). Importantly, however, CMS clarifies that hospital property does not include physician offices, rural health clinics, skilled nursing facilities, other entities that participate separately under Medicare, or restaurants, shops and other non-medical activities."

Question From D. Linnum:

The regulation states that the Central Log needs to indicate if the patient WAS REFUSED treatment. We understand that a patient cannot be refused treatment after presenting to the ED. Can you explain what would be an example of when a patient is refused treatment, and why this would be an option?

Answer:

I believe this is referring to situations after a patient has had an appropriate MSE and stabilization of any EMC. Once those requirements are met, the EMTALA obligation ends.

Question From D. Majka:

If a hospital ED goes on diversion, meaning they say they are overloaded, how does EMTALA apply?

Answer:

For the circumstances you describe, it sounds like the ED would not be in a position or have the capability to accept a transfer. However, remember there may be circumstances when the ED does not have capabilities, but other units of a hospital might have the capabilities (e.g., a burn unit or NICU).

Question From J. Wilke:

What if a psychiatric unit that has specialized limitations refuses a transfer because they feel the patient does not meet their capabilities, such as a patient that is drug and alcohol dependent? Units throughout the country often have limited capability (e.g., they don't take patients with a history of violence to staff, drug dependence, etc.) Thoughts? Any cases you can reference where government did not agree with not accepting a requested psychiatric transfer?

Answer:

The answer to this question is going to be fact-specific for the case. It will most likely come down to whether or not the psychiatric unit has the capability and resources to care for the patient. It should go without saying that the ability to pay, or the patient's insurance type, should not be a part of the decision-making process.