Revised guidelines shed light on confusing cases
Hospitals get timely advice on avoiding risk
Several aspects of the Health Care Financing Administration’s (HCFA) new interpretive guidelines for enforcement of the Emergency Medical Treatment and Active Labor Act (EMTALA) hit particularly close to home, says Cynthia A. Frizelle, RN, BS, assistant director of admissions/registration at UCSF Stanford Healthcare in San Francisco.
A seminar sponsored by the Sacramento-based California Healthcare Association (CHA) provided insights on handling recent patient cases at her organization, as well as timely advice on avoiding potential violations, says Frizelle, who recently moved to her position at Stanford from the UCLA Medical Center in Los Angeles.
One guideline revision states that the lack of an established emergency department (ED) does not mean emergency services aren’t provided, she points out. It defines the ED as any hospital service that provides emergency services, which is important from an access standpoint, she says.
"That could include labor and delivery or psychiatric [facilities]. Along the same line, if a patient needing emergency care comes to a treatment site that is contiguous to where the hospital’s ED sits, staff in that area must perform a medical screening exam within that site," she notes. "That really puts any area on the hospital campus at risk. A parking lot structure, if on campus, could be subject to following EMTALA guidelines, so that a medical screening exam must be done.
"If a patient comes to, say, an urgent care setting or a clinic and says, I need emergency service for severe pain,’ whether or not that person has a scheduled appointment, the clinic staff must perform a medical screening even if the patient does not have sponsorship (insurance coverage)," Frizelle adds. "They can’t [according to the guidelines] send the patient to the ED to be evaluated, which is usually what happens if they don’t have sponsorship."
Off-campus clinics billing under the hospital’s Medicare provider number are considered part of the hospital, and must comply with EMTALA, according to the revisions.
It is illegal to ask patients for a co-payment or for any type of financial information, she notes, even if patients offer to call their HMOs. "You can only get enough information to start a medical record." The key is that all patients with the same medical condition be treated in the same way, she says. "You can only move a patient if there is a bona fide medical reason to move the patient, or if all patients are handled the same way."
The new interpretive guidelines also specify that a patient presenting at any part of a health care organization — whether it be ED, off-site clinic, or another site — asking for emergency care must have his or her name entered in a central log for the entire organization, Frizelle says. Each area may have its own log, but the names eventually must be combined in the central log, which must be available to a HCFA surveyor in a timely manner.
A potential risk situation that UCSF Stanford Healthcare is clarifying, she says, involves the handling of self-pay ED patients. "We have financial counselors who go into the ED setting and help patients there," Frizelle explains. "Many times, the clinical staff just tell us there’s a self-pay account in room three. The patient must be cleared [by a medical screening exam] before we go in and start talking about finances, so we have to make sure everyone involved is educated about the process."
As part of its employee education efforts in this area, UCSF Stanford recently developed a "Code of Conduct and Principles of Compliance," which covers EMTALA as well as other regulatory and ethical issues, she says. (See related story, at right.)
The EMTALA section of the code states that UCSF Stanford complies with all federal and state laws and regulations regarding evaluation, treatment, discharge, and transfer of patients with emergency medical conditions. It gives pertinent information about the required medical screening exam, emphasizing that triage is not considered to be a medical screening. It further states that a notice informing patients of their rights under EMTALA will be posted at all times in the organization’s emergency departments.
Cloudy issues now in focus
Two cases Frizelle was involved with at a tertiary care center were clarified by the EMTALA consultant at the CHA seminar, she notes:
One case involved the transfer from another facility of a post-partum woman who needed a liver transplant. "MediCal wouldn’t cover the cost of a transplant, but the other hospital agreed to paythe MediCal rate, to sponsor the patient, and we would take the patient and continue to try to get MediCal to cover it. After the fact, [the transferring facility] refused to pay us, saying we were violating COBRA."
Frizelle learned at the seminar, she says, that the receiving facility under no condition was obligated to take a patient from another inpatient facility, once the patient had been admitted to that facility. "We did take the patient anyway, and now the case is in litigation."
The other case had to do with another hospital’s efforts to get the tertiary care center to take an inpatient who needed neurosurgery because of a subarachnoid hemorrhage, on the grounds that the first hospital did not perform neurosurgery, she says.
"HCFA’s stand is, once the screening process is done [at the other facility] and they’ve admitted the patient, we don’t have to do that."
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