How triage exam applies to EMTALA requirements
To the editor: The Emergency Medical Treatment and Active Labor Act (EMTALA) was referenced in the December 1996 issue of Healthcare Risk Management, p. 155. The article discussed HCFA’s definition of an appropriate medical screening examination and stated that a triage examination "does not count for complying with COBRA."
The language of the statute reads that "the hospital must provide for an appropriate medical screening examination within the capability of the hospital’s emergency department." Neither the statute nor the regulation defines the phrase "appropriate medical screening examination."
In the June 22, 1994, Federal Register, HCFA stated that each hospital must determine formally what type of personnel are qualified to perform the initial medical screening examination. HCFA notes that the U.S. Department of Health and Human Services is not required to accept the hospital’s specification and may, in some instances, determine that there was not an appropriate medical screening examination if the conditions of the patient required the expertise of a physician to determine whether that individual had an emergency medical condition.
Although it is generally accepted and advisable to have a physician perform the medical screening exam, HCFA recognizes that there may be hospitals that do not have a physician available, or there may be circumstances that are so clearly not emergency medical conditions that other qualified medical personnel may conduct the initial screening examination. [59 Fed Reg 32099 (June 22, 1994).]
The term "appropriate" has been interpreted by several courts as meaning uniform application of emergency department screening procedures. These courts have held that a hospital fulfills the appropriate medical screening requirement when it conforms its treatment of a particular patient to its standard screening procedures. The statement that "triage does not count" is misleading since the process of triage varies widely and may, in some circumstances, meet the intent of the statute.
The article also recommended that the medical screening examination be conducted before asking about insurance. The law states that "a participating hospital may not delay an appropriate medical screening examination . . . in order to inquire about the individual’s method of payment or insurance status." However, it is noted in the preamble that hospitals may continue to follow reasonable registration processes, including requesting insurance information, as long as these procedures do not impede the provision of necessary treatment and as long as all individuals to whom the procedures apply are treated similarly. This statement recognizes that immediate examination and treatment may not be necessary in all cases, and thus, inquiry about payment or insurance would not constitute a delay. A recommendation that the patient always be examined before asking about insurance is overly cautious.
The ambiguity of EMTALA’s language continues to plague risk managers and requires an in-depth understanding of the statute and regulations as well as an awareness of the applicable federal circuit and state court decisions.
Lynn Tenerowicz, RN, JD
Risk Manager, Baystate Medical Center
Springfield, MA
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