1. EMTALA Emergency Medical Treatment and Active Labor Act THE LAW and COMPLIANCE REQUIREMENTS Developed by Kathy Finch Clinical Operations Director Emergency Department Duke University Hospital

2. Historical Information  1983 200,000 patients denied emergency care for financial reasons  1984 growing # of ED Patients are uninsured  1986 avg. 250,000 economic transfers per year  1985 COBRA (Consolidated Omnibus Budget Reconciliation Act) Passed

3. Intent of the Law Stop denials for care or transfer of patients based on inability to pay Federally mandate a standard of practice for hospitals and physicians Prevent “patient dumping”

4. Basic Information About the Law Known as COBRA, EMTALA Statute found in the Social Security Act 1988, amended to include on-call physicians and care of patients in Labor Hospitals are not to make any verification, pre-authorization calls to payers prior to completion of a Medical Screening Exam. Site review guidelines can by viewed online www.medlaw.com

5. Basic Information About the Law Enforcement Center for Medicare and Medicaid Services (CMS) investigates and enforces the statute Regulatory issues Fraudulent billing practices Office of Inspector General (OIG) of the Dept. of Health and Human Services is responsible for enforcement Termination of hospital / physician eligibility to receive reimbursement for services rendered

6. CMS Enforcement Process Violations must be reported by receiving hospital within 72 hours There are sanctions for not reporting State must report cases to regional office Surveys are unannounced and focused Nature or particular case is not discussed during the investigation CMS issues a notice and Medicare participation is terminated unless suitable plan of correction with re-survey

7. CMS Enforcement Process A hospital’s failure to report can result in termination from Medicare/Medicaid services A hospital has two choices if a violation is substantiated: 1. Submit and follow through with a corrective action plan 2. A hospital whose Medicare/Medicaid services have been terminated has the right to appeal

8. How Investigations Proceed Reviewers will request ED log for past 6 – 12 months. AMA, LWBS, returns within 48 hrs, delays ED policy and procedure manual Consent forms for transfers of unstable patients Transfers to other facilities and returns Deaths and adverse outcomes Refusal of examinations

9. How Investigations Proceed Reviewers will request ED Operations and Staff meeting minutes for past 12 months Staffing schedules Bylaws of the Medical Staff Current staff rosters Physician on call lists

10. How Investigations Proceed Reviewers will request Performance Improvement Plan and performance outcomes List of contracted services Personnel records (optional) In-service training program, records, schedules, reports

11. How Investigations Proceed Medical Record Review Reviewers are looking for the following: Appropriate medical screening exam Treatment delays Unsafe transfer of a pregnant woman to delivery Appropriate stabilization Appropriate transfer and transferred by qualified personnel with appropriate equipment On-call physician response time was reasonable

12. Law has broad language and application “ if any individual…comes to the emergency department … “..the hospital must provide for an appropriate medical screening exam (MSE) within the capability of the hospital”

13. Duties of a Hospital Medical Screening Exam (MSE)  All patients must have an MSE completed and documented  The MSE includes physical exam + diagnostic procedures required to determine whether or not an Emergency Medical Condition exits.  Payment can not be requested or required until discharge  MSE must be non-discriminatory.  MSE must meet a reasonable standard of care  NOTE: Triage is NOT considered a MSE

14. Duties of a Hospital Medical Screening Exam and The Patient Record MSE must be timed and documented in the Medical Record plus: Log entry with disposition Triage record On going vital signs recorded History, Physical exam Documentation of stabilization procedures Tests required to rule out EMC Use of on call specialist to diagnose and stabilize patient Discharge/ transfer vital signs

15. Duties of a Hospital Medical Screening Exam Recommend that Non physician MSE be supervised

16. Duties of a Hospital r/o Emergency Medical Condition Inadequate screening for EMC is the major reason for reported COBRA / EMTALA violations  Condition that is a danger to health and safety of an unborn fetus  Life, Limb threatening condition  Condition of sufficient severity:  Severe pain  Psychiatric disturbances  Substance abuse  Active labor

17. Duties of a Hospital r/o Emergency Medical Condition  undiagnosed acute pain  potential for impairment to a bodily function  could result in dysfunction of an organ or part Pain must be assessed Medical Screening Exam to rule of EMC must be documented Labs, CT, X-rays may be required to R/O EMC

18. Duties of a Hospital r/o Emergency Medical Condition  Pregnancy  Legally defined as unstable  Considered an emergency if active labor / contractions  Can not transfer if birth is imminent  Can not transfer if threat to health or safety of the mother or unborn child  Not stable until the placenta is delivered

19. Duties of a Hospital r/o Emergency Medical Condition  Psychiatric Patients  Substance Abuse  Must have a documented medical screening exam  Transfer must be safe and appropriate

20. Duties of a Hospital Stabilization Treatment to assure, within reasonable medical possibility, that no further deterioration of the patient’s condition is likely to occur during a transfer Applies to in house transfers

21. Duties of a Hospital Transfer of an Unstable Patient Transfer is defined as any time a patient leaves the campus of the hospital, including discharge, unless AMA or deceased Do not transfer unstable patient if the hospital has the capabilities and physical capacity to treat the patient Unstable Patient can be transferred for medical necessity – benefits > risks must be documented Physician convenience or practice is not a permissible reason for transfer

22. Duties of a Hospital Transfer of Unstable Patient Transfer requirements Physician certification – benefits > risks must be documented Written request for transfer by patient Documented advanced acceptance of receiving hospital and physician by name Written consent Appropriate transfer mode, personnel and equipment Copies of Medical Record, tests, x-rays, CTs are to accompany patient

23. Duties of a Hospital Accepting Unstable Patient Transfer Hospital has specialized capabilities needed by the patient Sending hospital is less able to care for patient Patient must be accepted without regard to ability to pay or third party payer involvement Hospital may decline transfer No room May refuse a lateral transfer Hospitals are at great risk if they decline to take a patient

24. Duties of a Hospital Maintain On-Call System Provide coverage to assist in stabilization On-call physician must respond to the hospital or ED – not permissible to send patients to office for definitive care On-call list must be posted and revisions noted – maintain for 5 yrs On-call list must include every specialty privileged in the hospital Minimum on-call rule

25. Duties of a Hospital Reduce Delays  Log arrival time – pre triage  Triage by a nurse within 10 minutes of arrival  Time to medical screening exam within 30 minutes or reassess  No delay in screening or stabilization in order to inquire about the patient’s method of payment or insurance status

26. Duties of a Hospital Reduce Delays  Must have a plan to manage delays and overload:  Protocols and subsystems to begin medical screening  Critical Saturation Policy to manage overflow  Clear policies for Trauma Divert  Clear policies for Local Ambulance Divert

27. Duties of a Hospital Reduce Delays  Important to note:  LOCAL RED TAG PATIENTS CAN NOT BE DIVERTED, MUST BE SENT TO THE NEAREST FACILITY FOR STABILIZATION THEN TRANSFER -- IF IN OVERLOAD

28. What can we anticipate?  Trend will be to expand parameters of the law  OIG has increased its resources  Disparity in interpretation of the law in the courts, between State and Federal authorities  More likely to be found non-compliant since the interpretation of rules is not standardized

29. What can we expect?  CMS is not obliged to follow the decisions of any court ruling  Federal law supercedes State laws  EMTALA violations:  courts look for discrimination  CMS looks for refusal of care or fraudulent billing practices

30. What can we expect?  Law will expand the authority of CMS  Inpatient as well as outpatient compliance  Emergency situations, on call, transfers  Delays will be considered as non-compliance  Activate overload subplans  On call rules  Standards should be set in the hospital bylaws

31. Common Violations  Failure of on call systems  Failure to do a medical screening exam  Improper screening of psychiatric patients  Failure to stabilize before transfer  Failure to provide protected transfers due to lack of written procedures and standardization  Incomplete document: compliance is not verifiable

32. Common Violations  Careless billing practices --- viewed as fraud  Discharge planning is incomplete and not thoroughly documented  Condition / Vital signs at discharge  Patient Education  Referral and follow up  Appropriate Transfer  Transfer policy and procedures not followed

33. Concluding Thoughts  Federal Law requires 100% compliance to all care, process and documentation standards  Must comply to Federal Law  Integrate the requirements as part of your policies, procedures for standards of care, documentation and billing  Document the training for physicians and nurses

34. ED EMTALA Compliance Checklist Policies and procedures must comply with EMTALA Post signs in the ED: patient’s right to MSE to rule out EMC Hospital’s participation in Medicaid program List of on-call physicians EMTALA compliant central log

35. ED EMTALA Compliance Checklist Documented MSE Documented Stabilization Transfer policies No delays to MSE Accept appropriate patient transfers with medical emergencies

36. Questions go to Lynette