CMS clarifies EMTALA rules in light of H1N1
Triage issues and preventing ED overflow
In anticipation of a possible significant increase in demand for emergency services due to H1N1 influenza resurgence this fall many hospitals have expressed significant concerns about compliance with "patient dumping" laws, the Centers for Medicare & Medicaid Services reports.
One of the key issues is patient triaging — which may occur beyond the emergency department — and compliance with the Emergency Medical Treatment and Active Labor Act (EMTALA). "Many stakeholders perceive that imposes significant restrictions on hospitals' ability to provide adequate care when emergency departments (EDs) experience extraordinary surges in demand," the CMS stated in a recent clarification on the issue. "[A]n EMTALA-mandated medical screening examination (MSE) does not need to be an extensive work-up in every case, and the MSE may take place outside the ED, at other sites on the hospital's campus."
One of the infection preventionists seeking clarification on the issue was Susan Kraska, RN, CIC, of Memorial Hospital in South Bend, IN.
"We needed guidance on what we could provide for folks and still be within the law under EMTALA," she says. "What if 40 people come for [flu] screening and someone else has chest pains? We want to be able to meet the screening folks needs but also the chest pain needs. We are looking at triaging [flu patients] into a different area."
Triaging symptomatic flu patients for screening to another area of the hospital campus should prevent the ED from being overrun and stay within the law, says Alexander Isakov, MD, MPH, executive director of the Emory University Office of Critical Event Preparedness and Response in Atlanta. "As long as your alternate site is still on hospital property, it probably meets the spirit and the even the letter of the EMTALA law," he says. "If you are referring mild acuity to an alternate location, that is probably fine. Our approach is that it is good to redistribute load, especially of mild illness, of people presenting at your front door."
Many hospitals are planning to set up triage sites stocked with masks outside the ED so they do not have symptomatic patients simply walking through the doors unmasked.
"Trying to keep a large volume of flu patients with mild symptoms out of that emergency room [is a good idea] for both ED patients and those who have mild flu-like illness," Isakov says. "They can go to an area where they are treated in a more efficient manner and not fall victim to being triaged behind more serious illness of all kinds. It actually works really well for the ED and the health care system if you can 'decompress' mild illness to another area of the hospitals in a so-called flu clinic."
CMS Q&A
The CMS also provided some answers to the following frequently asked questions:
Question: Is it permissible for a hospital to triage individuals with suspected cases of H1N1 flu virus infection to an alternative site for evaluation under EMTALA? If so, how do we bill for these services?
Answer: Under current EMTALA law and regulations, hospitals are permitted to move individuals out of their dedicated emergency departments to another part of the hospital (on the hospital's same campus) in order to provide the required MSE and, if an emergency medical condition is found to exist, to provide stabilizing treatment or arrange for an appropriate transfer.
Sometimes hospitals refer to these as "fast-track clinics" and use them either all year round or during surge in demand for emergency department services during the seasonal cold and flu season. The medical screening examination provided in the "clinic" must be performed consistent with the requirements of the EMTALA provision, by qualified medical personnel who can perform an MSE that is appropriate to the individual's presenting signs and symptoms.
If, prior to directing the individual elsewhere in the hospital, qualified medical personnel in the emergency department completed an appropriate MSE and determined that the individual does not have an emergency medical condition, then the hospital has no further EMTALA obligation to that individual and the issue of moving the individual to an alternate site, either on or off the hospital's campus, would be moot from an EMTALA perspective.
For services rendered to Medicare fee-for-service (FFS) beneficiaries, standard Medicare FFS billing rules apply. Hospitals should work with their other payers to determine if special billing rules may apply.
Question: What is HHS' process for approving and issuing EMTALA waivers for hospitals that have implemented hospital disaster protocols in response to an emergency?
Answer: There are four prerequisites for a hospital waiver of EMTALA sanctions under HHS' authority under Section 1135 of the Social Security Act. They are as follows:
1) the President has declared an emergency or disaster under the Stafford Act or the National Emergencies Act;
2) the Secretary of HHS has declared a Public Health Emergency (PHE) under Section 319 of the Public Health Service Act;
3) the Secretary of HHS has invoked his or her authority under Section 1135 of the Social Security Act and authorized CMS to waive sanctions for certain EMTALA violations that arise as a result of the circumstances of the emergency;
4) the hospital in the affected area has implemented its hospital disaster protocol.
Question: Will Medicare cover and pay for a surgical mask to prevent the spread of infection from H1N1 flu, if prescribed by a physician?
Answer: No. There is no Medicare benefit category that would allow for separate coverage of a surgical mask.
Question: Will Medicare pay for diagnostic tests for swine H1N1 flu (e.g., nasal swabs) for beneficiaries?
Answer: Under Part B, Medicare will cover diagnostic tests as set forth in 42 CFR 410.32 and other existing policies. We note, however, the Social Security Act does contain exclusions that would bar payment if an item or service was provided free of charge or in other circumstances.
Question: States are distributing CDC's Strategic National Stockpile (SNS) drugs to hospitals. We are looking for official guidance from a "billing" perspective to share with our members. How should hospitals handle billing for services that involve the use of SNS provided drugs?
Answer: For services rendered to Medicare fee-for-service (FFS) beneficiaries, standard Medicare FFS billing rules apply. This would include following existing policy on no cost items, such as SNS drugs. Hospitals and all providers should work with their other payers to determine the acceptable way to bill those payers for services related to free drugs/tests.
In anticipation of a possible significant increase in demand for emergency services due to H1N1 influenza resurgence this fall many hospitals have expressed significant concerns about compliance with "patient dumping" laws, the Centers for Medicare & Medicaid Services reports.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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