EMTALA – Module 2 42 U.S.C. §1395dd HomeTown Health Educational Workshop Michele Madison and Brynne Goncher

Compliance review for Dedicated Emergency Department Establish that the Department satisfies the Dedicated Emergency Department tests to determine if EMTALA applies If EMTALA applies, verify that the Dedicated Emergency Department has the completed the following items:

Requirements for DED Administrative Requirements: 1. Adopt and enforce policies and procedures to comply with EMTALA 2. Post signs regarding rights of the individuals with emergency medial conditions/labor and any participation in Medicare 3. Maintain medical or other records related to individuals transferred to and from hospital for 5 years 4. Maintain list of physicians on call to provide treatment or stabilization 5. Keep a record of patients who presented and status (refused, denied, treated) 6. Provide Medical Screening

Additional DED Requirements Administrative Requirements: 7. Accept appropriate transfer of individuals with an emergency medical condition if the hospital has specialized capabilities or facilities and has the capacity to treat those individuals; 8. Not penalize or take adverse action against a physician or medical person because they refuse to authorize the transfer of an individual with an emergency medical condition that has not been stabilized, or reports a violation

Enforcement Civil Monetary Penalties $50,000 fine for Hospital $25,000 fine for Hospital with less than 100 beds Physician’s violation --$50,000 fine Civil Enforcement Patient civil actions for losses Hospital’s civil action for financial loss caused by a violation of another Hospital of EMTALA

Reporting Deadline for Suspicious Transfers Hospitals who suspect an improper transfer should report transferring hospital within seventy-two hours of occurrence 72 HOURS

Survey Process 1.Entrance Conference 1.Explain nature of allegation 2.Purpose of investigation 3.Requirements 4.Identification of Complaining party will not be disclosed 2.Document requests during Entrance Conference 1.ED Logs 2.Policies for ED and Medical Staff 3.On Call Lists 4.Transfer forms, etc.

Survey Process 1.Case Review 1.Review a sample of charts with similar or like circumstances 1.Transfers 2.Consents for Treatment 3.Pregnant Patients 2.Review all records 3.Interview Staff which may include clinical and administrative staff 4.Exit Conference at Facility

Survey Process 1.Professional Medical Review Conducted 2.Assessment of Compliance or Deficiencies 3.Facility then responds to any Deficiency Report within a set time frame 4.The Work Plan is reviewed for compliance 5.Fines are evaluated 6.Hearing on Level of Fines is afforded to Facility or Physicians 7.Determination is made

Case Analysis #1 The Emergency Room is crowded. A patient is in a motor vehicle accident. The patient presents to the Dedicated Emergency Room. A nurse triages the patient and moves the patient to a room. The Physician examines the patient and determines that the patient has a broken arm, laceration to the head and potential punctured lung. The Physician orders an exam from respiratory services to verify the status of the lung and respiratory functions of the patient.

Case Analysis #1 While in the holding room, the nursing assistant caring for the patient tells the patient that it has been crazy in the Emergency Room that day; the Emergency Department is understaffed; and it will be a couple of hours before the test can be performed. However, the Hospital two miles away is never busy and has a ton of doctors and nurses all the time. There is a wait to obtain the respiratory services test. The Patient is moved to a holding bed in order to open the room for a second motor vehicle accident victim with a broken skull.

Case Analysis #1 When the nursing assistant returns to the central desk, patient leaves hospital and goes to the hospital down the street for care. Is there an EMTALA violation?

Case Analysis #2 A patient presents to the Emergency Department with a cough and sniffles. A nurse triages the patient and sends patient to waiting room to wait. After waiting in the emergency room for two hours, the patient leaves the emergency room. Is there an EMTALA violation?

Case Analysis #3 Illegal Alien, who is working for a construction company, arrives in Emergency Room with a nail in the eye. Patient taken directly back to a room. The registration clerk goes to the room and asks the patient for his or her social security number to create a chart without asking for any insurance or payment information. Patient informs registration clerk that he or she does not have a social security number and explains that he or she is just working for the winter and then will leave the country. Does the Hospital have to perform the emergency medical screening?

Case Analysis #4 Hospital has a program to collect co-payments, deductibles and coinsurance at the time of the patient’s visit. Hospital posts a sign in the Emergency Room stating that Co-payments and Deductibles will be due at the Time of Service. Is there an EMTALA violation?

Case Analysis #5 Hospital cancels its Managed Care Contract with Third- Party Payer which causes it to be out of network for patients with this insurance. Hospital posts a sign on the Entrance Doors for the Emergency Department and the Main Doors to the Hospital which reads: Is there an EMTALA violation? Hospital does not participate in Third Party Payer Program. Patient is responsible for out of network charges.

Case Analysis #6 Patient Presents to Emergency Department with chest pains. Patient is triaged and brought directly into a room. The registration clerk proceeds to the room and while the Physician is conducting the medical screening requests information for the “reasonable registration” including patient name, social security number and date of birth. Upon entering the information, the registration clerk determines that the patient has been to the Hospital before and the Hospital is no longer participating in the insurance program.

#6 continued Can the Registration Clerk notify the patient during the Medical Screening? Can the Registration Clerk notify the patient after the Medical Screening is completed if the patient is determined to have an Emergency Medical Condition?

Case Analysis #7 Patient is injured in car accident and ambulance owned by Hospital A arrives at accident scene. EMS puts patient into ambulance and arrives at Hospital B, which it has been directed to go to due to community-wide protocols. Hospital B is unwilling to accept patient, stating that the patient is Hospital A’s problem since it is Hospital A’s ambulance. Has either Hospital A or Hospital B violated EMTALA?

Case Analysis #8 Police officer arrives in his police car with individual in the back seat. The officer assists the individual from the back seat into the emergency department. The individual is slurring her words, walking with a limp, and has numerous lacerations on her face, arms and legs. The officer requests a blood alcohol test, a nurse says that the individual should be screened, but the officer says no, she’s fine. The nurse performs the blood alcohol test, the results are positive, and the officer takes the individual to the police station. Is there an EMTALA violation?

Resources Centers for Medicare and Medicaid Services United States Code Emergency Medical Treatment and Labor Act : 42 U.S.C. §1395dd; §§1866(a)(1)(I), 1866(a)(1)(N), and 1867 of the Social Security Act; 42 C.F.R. § Morris, Manning and Martin, LLP Michele Madison Brynne Goncher