EMTALA guidelines: Here’s what your ED needs to know
By Staci Bonner
The long-awaited revised guidelines for enforcement of the Emergency Medical Treatment and Active Labor Act (EMTALA) have finally been published, effective July 14, 1998. ED managers have been waiting for the guidelines since June 1996, when the EMTALA Task Force held its first meeting.
"We have definitely taken some positive steps forward with better clarifications, but this is only the beginning," says Charlotte Yeh, MD, FACEP, chief of emergency medicine at New England Medical Center in Boston and a member of HCFA’s task force on EMTALA. "Not all our questions were answered, but those that were addressed are significant improvements."
Here is an overview of the significant changes:
The medical screening exam (MSE) is a process, not an event. The guidelines clarify the definition of an MSE, giving the example of a severe headache that could require extensive testing, including a CT scan and/or lumbar puncture. "You can substitute chest pain or abdominal pain for that," says Larry Bedard, MD, FACEP, director of emergency services at Doctor’s Medical Center, San Pablo and Pinole campuses and immediate past president of ACEP. "The screening exam is not necessarily a Level 1 or 2 code. It may be a comprehensive evaluation or level 5 code."
There is a clear acknowledgment that triage does not constitute an MSE, says Yeh. "The MSE is a process, not a single event, required to determine the presence or absence of an emergency medical condition," she explains. "That could be as simple as a history and physical, or as complex as multiple diagnostic procedures and ancillary services."
The new definition of a MSE is likely to affect the financial reimbursement an ED receives, says Yeh. "Because the definition covers such a broad range of services, it’s important that any discussions with third party payors should assure payment for a full range of services, from simple to complex," she stresses. "Accepting a low level single fee may not cover the full range of services you are required to provide under the law."
Prior authorization is not allowed. The guidelines clearly state that prior authorization is not permitted before an MSE and stabilizing treatment, Yeh explains. "It was not ever permissible to delay an MSE, but before it was not as clear," she says. "Now, it’s explicit as opposed to implicit."
Now, if a hospital calls for prior authorization, they are violating the law, says Bedard. "Because the guidelines also clarify that triage is not the same as a MSE, you can’t have a nurse do triage and then turn around and call for prior authorization," he explains.
The change is extremely important, says Steven Frew, JD, a Rockford, IL-based health care attorney and consultant. "First and foremost is the flat out statement that there can be no prior authorization calls until there has been a complete screening and stabilizing treatment," he notes. "We often hear from managed care, Let’s see it in writing.’ Well, now it is."
Some procedures can be done outside the ED, if there is a follow-up plan of care. "There is a reference to deferring some testing for referral as outpatient basis, but only if a patient is under a plan of care," says Frew. "Many people thought this would be an opportunity to limit the amount of care given in the ED and allow referring out. But, it is clear that HCFA will still expect a high level of stabilization and treatment before the patient leaves."
If anything is necessary for diagnosis or stabilization, it’s still going to have to be done in the ED, says Frew. "So, it really only allows for marginal testing and follow-up that was not permitted before, to be done outside of the ED. It is a major trap for the unwary."
The guidelines also include an important caveat, that the physician who accepts that referral has to follow through on it, says Frew. "In the past, these referrals have gotten made, the patient presents to a physician’s office who demands money to see them, and the patient goes untreated," he notes.
HCFA will continue to cite those cases as patient dumping. "The physician who accepted the referral is obligated to do follow-up care," says Frew. "You can’t refer patients out without safeguards in place to make the physician responsible," he explains. "As is often the case, what looks like an opportunity to circumvent EMTALA is a major trap for the unwary."
The new regulations address the issue of when patients are considered stable for discharge. "It’s consistent with the standard of care in clinical practice that it may take time to make the diagnosis of appendicitis," says Bedard. "This reduces the jeopardy of sending these patients home. You can do that if there is reasonable follow-up, whereas before we were required to keep the patient in the ED until the diagnosis is made, sometimes hours later."
The legal definition of stabilization under EMTALA is not necessarily the same as the medical definition of stabilization, notes Yeh. "Under the legal definition, if you are going to transfer somebody, the patient is considered unstable if there is a risk of material deterioration," she says. "But typically, a physician could be taking care of a very critical patient whose vital signs are constantly in flux. Still, you clearly need to transfer the patient, because you don’t have the appropriate resources at your institution."
Even if physicians do everything they can to ensure the patient gets safely from one hospital to the other, the patient is still not legally stable. "In the provider’s mind, they’ve done everything they can (for example, IV monitoring, medications, etc.) to minimize any deterioration arising during transport," says Yeh. "But that’s not stable’ under the law, because the patient still has a risk of deterioration. It’s a very tough concept for providers to understand."
The legal definition of stabilization must be considered when transferring patients. "There is nothing that prevents you from transferring an unstable patient. You just have to fulfill the appropriate transfer requirements," says Yeh. "And it’s not good enough to say the benefits outweigh the risks. You have to outline the specific benefits."
The examining physician is the one who determines whether the patient is stable. "They did include the word usually’ to qualify that, but it’s a definite improvement from the previous language," Bedard says. "This way, you don’t run into the situation where an HMO gatekeeper says, From your description, I think the patient is stable, so send them home and we’ll see them tomorrow." The HMO physician does have the option of coming in and examining the patient themselves, but they cannot make that decision over the phone, he explains.
Peer review is recommended when medical judgment is involved. "ACEP wanted it to be mandated that if a violation involved a question of medical judgment, HCFA had to get peer review," Bedard says. "The revised guidelines made it a recommendation but not a requirement. But it does say if they do get a peer review, they should try and have someone in the same specialty—an ED physician as opposed to a cardiologist."
90 days notice can be given for administrative violations. Previously, any EMTALA violation called for a 23-day notice to complete a corrective plan, regardless of whether there was immediate danger to patients. "Now, there is a recognition that not every EMTALA violation mandates a 23-day termination process—that there are times when a 90-day review process is acceptable," says Yeh.
Previously, some hospitals were given 23 days notice because they failed to send a copy of the patient’s medical record, says Bedard. "If it’s a matter of clinical decision making, then 23 days is appropriate, but the new guidelines allow for 90 days notice if it’s simply administrative," he explains.
On-campus sites must have the same provider billing number as the hospital. HCFA added language that allows hospitals to complete or conduct the MSE outside the ED only if the patient is sent to a hospital-owned facility on the hospital’s physical campus and is operated under the hospital’s provider number.
This is problematic, says Bedard. "Routinely we’ll send patients to outpatient offices for procedures such as minor tendon repairs," he notes. "It’s a step backward to say you can only transfer a patient if the clinic has the same provider billing number."
The new language will have unintended consequences, Bedard explains. "What this does is potentially extend EMTALA to the third of the ambulatory care centers that are owned by hospitals," he says. "You can have a hospital-owned occupational medical center staffed by independent contractors, which will now come under EMTALA. This is extending the requirements in a way that was never intended."
If a group of pediatricians staff a clinic in the hospital with their own provider billing number, it will fall under EMTALA, says Bedard. "Physicians who operate as independent contractors are not hospital employees, so they will have a different provider number," he explains. "Under the new guidelines, an ED physician would have to fulfill all the requirements of an appropriate transfer’ to send a patient across the hall to that pediatric clinic."
Hospital-owned EMS plans will find it easier to comply with EMTALA. "Previously, if ground transportation took a patient to the hospital helipad so the helicopter could bring the patient to a Level 1 trauma center, the hospital would have been required to do a full MSE and stabilization beforehand, because they were using the hospital helipad," notes Yeh.
Under the new guidelines, since the EMS protocols state that patients should be transported as quickly as possible, the hospital will generally be deemed compliant, says Yeh. "They are using the helipad as a means to meet the helicopter, and the hospital is following regionally approved EMS protocols. Therefore, they are not required to do the full MSE and stabilization," she explains.
Hospitals’ EMS plans need to be community-based, stresses Frew. "If you put together a community EMS plan and patient choice is part of that plan, you might get around the necessity of signing a refusal in the field," he says. "All players must be involved, not just the hospital. It must include the dispatchers, police, and fire department."
EDs are in denial
Even after many hospitals have been issued citations, many are still violating EMTALA, says Frew. "There is a general sense of denial. The usual reaction is that interpretation can’t be right because it doesn’t make good business sense," he explains. "People don’t realize that if something makes good business sense, it is probably illegal under EMTALA or Medicaid fraud and abuse."
There are still commonly seen areas of citation, says Frew. "There are still preauthorization denials that shouldn’t have ever been happening but definitely cannot be happening now," he notes. "Also, we continue to see citations for on-call physicians refusing to come in."
Another hot spot is inadequate mental health screenings. "Almost every hospital I’ve seen in the Midwest that has been cited by HCFA has had several citations for this," says Frew. "Usually, at least one is a drug overdose or suicide gesture that was considered minor, and the patient didn’t get an adequate work-up and was discharged."
Many medical staff and administrators still don’t understand the obligations of EMTALA, says Bedard. "There is still a lot of confusion about how to comply," he stresses.
Some hospitals believe they are in compliance but don’t understand the depth of the legislation, says Frew. "Others follow their HMO rules because they think they’re supposed to and don’t realize that federal law supersedes them, he reports. "So, they follow their state Medicare procedures and get nailed for a violation."
Others know the law but willfully violate it, says Frew. "For financial reasons, some administrators choose to interpret it differently, figuring they will make enough money to make that worthwhile, even if they do get cited at some point," he explains.
But that assumption is dangerous, says Frew. "An EMTALA violation has potentially devastating financial effects," he emphasizes. "To give just one example, a hospital in Arizona ended up getting suspended from Medicare from November to June, due to EMTALA and other Medicare violations. According to inside sources, it cost them over $30 million out of their cash reserves."
Many areas are still unclear
One thing is clear: EMTALA is here to stay. "Even if the statute itself were to be revised, chances are it would be made even more stringent," says Frew. "In this climate of concern about patient protection, it would be almost impossible to get EMTALA amended, except to make it even tougher," he predicts. "No legislator would loosen patient protections that already exist."
The EMTALA Task Force, which has contributed input on a regular basis during the two-year process, is not scheduled to meet again. "It’s not clear if they will reconstitute the task force; however, it’s anticipated that there will be some mechanisms to continue the dialogue," says Yeh. "We hope that the discussion will continue on an ongoing, informal basis."
Still, the new guidelines won’t be the last chapter in the book on EMTALA. "This isn’t the end of the issue," says Frew. "My understanding is that HCFA will be sending out clarification letters defining issues such as the difference between a patient being stable, as opposed to stable for transport."
The more clarifications that are added to the site review guidelines, the more likely EMTALA will be applied uniformly, says Frew. "But the fact remains that just like traffic cops, HCFA inspectors can be subjective," he notes. "They all have prosecutorial discretion. They may choose to nail one person for an offense and let another by because they have a higher level of confidence in that institution."
ED managers need to be familiar with the actual EMTALA regulations in addition to the new guidelines, urges Yeh. "The guidelines do not change the law. They are just how HCFA will choose to interpret the statute," she says. "Ultimately, the key to compliance is really to assure that patients, whether in the ED or elsewhere, are treated in a nondiscriminatory fashion."
Here are some areas that may be addressed:
Transfer from a hospital after being admitted. "The guidelines do not address the scenario of a patient being admitted to a hospital and transferred to another facility days or weeks later," Bedard notes.
One patient who was transferred after being admitted has pressed an EMTALA investigation that will be the first to go to the Supreme Court, Bedard reports. "This is an important issue," he says. "The day the patient was transferred to a rehab hospital, she required admission to another acute care hospital. She went from acute care to extended care, to another acute care, claiming the first hospital should have kept her there."
The particular case hinges on whether the violation occurred because of monetary gain, says Frew. "If they confine it to the issues of the case, it won’t affect the general climate of EMTALA," he explains. "But it will be the court’s first chance to comment on the law at all, which will be interesting."
No discussion of finances. "To be completely safe, you can’t have any financial discussion whatsoever with a patient," says Bedard. "If an HMO patient came in and said, My HMO won’t do a back X-ray but I want one, how much will it cost me?,’ you can’t tell them. The attitude that you can’t tell the patient what the cost will be, or imply they won’t have any responsibility for payment is absurd."
The policy of never discussing finances violates consumer rights, says Bedard. "I don’t think there is any service in this society where you don’t have a right to ask for the cost," he argues. "I call this the HCFA gag rule."
Signage issues. The guidelines do not address what sign, if any, is permissible to post in the ED regarding patient responsibility for payment. "They can charge you with coercion if the patient leaves because you told them the bill would be expensive," says Bedard. "That could include posting a sign that says if insurance doesn’t pay, we’ll send you the bill."
More than half of the hospitals in the country have similar signs posted, he notes. "They could be interpreted as a form of coercion," says Bedard. "If that’s the case, HCFA has an obligation to notify two-third of the hospitals in the country that they are in violation of the law."
Dual staffing. There is a trend toward MCOs placing their own physicians in a hospital’s ED but only to provide treatment for patients who are plan members. In Denver, Cleveland, and North Carolina, Kaiser Permanente has closed its own facilities and signed a contract with a non-Kaiser facility for ED physicians to selectively see the HMO’s patients, reports Bedard. "Kaiser is aggressively moving forward with this option in California," he says. "This raises a tremendous number of issues with EMTALA."
The California chapter of ACEP has requested a ruling from HCFA on the legality of this arrangement, Bedard reports. "We will be seeing this situation more and more in this managed care environment," he says. "HMOs want to put their own physicians in the ED to see their own patients. But if you try and segregate them out, we think that violates EMTALA."
Psychiatric patients. "There needs to be a lot more education about psychiatric patients, because there continues to be a lot of confusion and variation in standards of practice," says Yeh. "People tend to think that a psychiatric screening exam is not required. But it’s very clear that these patients must have a full screening exam, both medical and psychiatric."
Editor’s Note: The EMTALA statute, regulations, and site review guidelines can be accessed at the following Web site: http://www.medlaw.com
Compliance with COBRA/EMTALA Screening Criteria
By Caral Edelberg, President, Medical Management Resources, Inc. Jacksonville, FL
Effective July 14, revised EMTALA guidelines will be used by HCFA regional offices and state survey agencies to enforce COBRA’s EMTALA provisions. The revisions provide a significant improvement by clarifying many of the more subjective elements of the regulations due, in part, to the efforts of the EMTALA Working Group, which included representatives from the American College of Emergency Physicians.
EDs will find these revised guidelines vastly improved as they more clearly define the responsibilities for compliance with COBRA/EMTALA regulations. Revisions to EMTALA define a hospital with an ED as one that offers services for emergency medical conditions within its capability to do so. Lack of an established ED is not an indication that emergency services are not provided. If a hospital offers emergency services for medical, psychiatric, or substance abuse emergency conditions, it is required, within its capability and capacity, to comply with all the anti-dumping statutory requirements.
An "emergency medical condition" is defined as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances, and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in: placing the health of the individual (or, with respect to a pregnant woman, the health of a woman or her unborn child) in serious jeopardy; serious impairment to any bodily functions; serious dysfunction of any bodily organ or part; or with respect to a pregnant woman who is having contractions; that there is inadequate time to effect a safe transfer to another hospital before delivery, or that the transfer may pose a threat to the health or safety of the woman or the unborn child.
EMTALA protection also extends to intoxicated individuals when the absence of treatment would place their health in serious jeopardy. Protection is also extended to those patients who appear suicidal or homicidal who, if determined to be dangerous to themselves or others, would be considered to have an emergency medical condition. In either case, the patient would be considered stable only after it is determined that he or she is no longer considered to be a threat to him or herself or others. Although the appropriateness of treatment should never be an issue, both intoxicated and psychiatric patients present special challenges for payment, particularly with managed care organizations who generally consider both problems to be outside the scope of their plan coverage for ED services.
Clarification of the Medical Screening Examination
Emergency services need not be provided in a specified ED. Patients who arrive on the hospital premises, including parking lot, sidewalks, and driveway of the hospital requesting emergency care are entitled to a screening examination. In essence, screening examinations may be provided in other areas or other departments. Screening examinations or stabilization that requires ancillary services may necessitate that the patient be directed to another area within or contiguous to the hospital. (Contiguous is defined as any area within the hospital or a hospital-owned facility on land that touches land where a hospital’s ED sits.) The caveat is that all persons with the same medical condition would be moved to the designated location 1) regardless of their ability to pay for the treatment; 2) when there is a bona fide medical reason to move the patient; and 3) qualified medical personnel accompany the patient. (Hospital property includes ambulances owned and operated by the hospital even though the ambulance is not on hospital grounds.)
Hospitals are mandated to screen all individuals who come to the hospital and request an examination or treatment for an emergency medical condition. It is never appropriate to merely "log in" the patient without providing a medical screening examination beyond initial triage. Triage is not equivalent to a medical screening examination. As clarified in EMTALA, triage merely determines the "order" in which patients will be seen, not the presence or absence of an emergency medicine condition. The medical screening exam must be the same medical screening examination that the hospital would perform on any individual coming to the hospital’s ED with the same signs and symptoms, regardless of his or her ability to pay for medical care. If the screening is appropriate and does not reveal any emergency medical condition, the hospital has no further obligation. Regardless of a positive or negative patient outcome, a hospital would be in violation of the statute if is fails to meet any of the medical screening requirements under the regulation.
A medical screening examination is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether a medical emergency exists. The hospital’s obligation extends to performance of medical screening examinations in a nondiscriminatory manner to assure that a different level of care does not exist based on payment status, race, or national origin in order to comply with EMTALA.
The medical screening examination is not an isolated event but, rather, defined as an ongoing process reflected in the medical record as continued monitoring according to the patient’s needs. Screening must continue until the patient is stabilized or appropriately transferred as evidenced in the medical record.
Medical screening encompasses a full spectrum of services from the obtaining of a brief history and physical examination to the more comprehensive evaluation involving ancillary studies and procedures. All are considered integral components of screening. Thus, screening is a component of each of the ED Evaluation and Management coding levels (99281-99285). Unfortunately, many payers continue to downcode or deny payment altogether for patients who, after receiving a medical screening examination, are determined not to have a medical emergency.
The hospital must formally determine who is qualified to perform the initial medical screening examination and provide the designation of these qualified individuals in a document approved by the governing body of the hospital. It is not acceptable to allow the medical director of the ED to make what may be informal delegations that could frequently change. Inspectors are required to investigate for evidence that policies and procedures for emergency medical services (including triage of patients) are established, evaluated and updated on an ongoing basis.
When disagreements related to transfer arise between the treating physician and an off-site physician, such as the physician at the receiving facility or the patient’s primary care physician not physically present at the transferring facility, the medical judgment of the treating physician will usually take precedence over that of the off-site physician. EMTALA provides that the clinical outcome of the patient’s condition is not considered the basis for evaluating the appropriateness of screening or stabilization of the transferred patient. Thus, determinations for violation may be made on the presenting problems, symptoms, and condition of the patient and not on the final outcome.
EMTALA and managed care
Managed care plans are specifically referenced in the revised EMTALA guidelines, and EDs are cautioned that they may not refuse to screen an enrollee of a managed care plan when the plan refuses authorization for treatment or refuses payment for screening and treatment. In its guidance to surveyors, HCFA provides the following interpretation of the ED’s responsibility as it pertains to enrollees of managed care plans. A managed health care plan (e.g., HMO, PPO) cannot deny a hospital permission to treat its enrollees. It may only state what it will or will not pay for. Regardless of whether a hospital will be paid, it is obligated to provide the services specified in the statute and this regulation. HCFA’s interpretative guidelines go on to clarify, a hospital may not refuse to screen an enrollee of a managed care plan because the plan refuses to authorize treatment or to pay for such screening and treatment. It is not appropriate for a hospital to request or a health plan to require prior authorization before the patient has received a medical screening examination to determine the presence or absence of an emergency medical condition or until an existing emergency medical condition has been stabilized. Once an emergency medical condition has been determined not to exist or the emergency medical condition has been stabilized, 1867 of the Act no longer applies and prior authorization for further services can be sought.
In the case of managed care hospitals, they, too, are prohibited from refusing to screen and treat or appropriately transfer individuals not enrolled in their plan who come to the plan hospital if the hospital participates in the Medicare program. Once the determination has been made that a medical emergency does not exist, the hospital has no further obligations under EMTALA.
The decision to discuss payment options or alternative sites of service with the patient must be made carefully. According to HCFA’s interpretative guidelines, hospitals are expressly prohibited from coercing individuals into making judgments against their best interest by informing them that they will have to pay for their care if they remain, but that their care will be free or at low cost if they transfer to another hospital or facility.
Although it is common for EDs to request financial information from patients, hospitals are prohibited from delaying a medical screening examination or necessary stabilization to inquire about the patient’s ability to pay for care. According to the EMTALA clarification provided to investigators, all patients with emergency conditions must be provided assistance regardless of their response to insurance questions asked during registration. Hospitals are not excluded from obtaining necessary information. However, they may not delay the screening or treatment process for patients with emergency conditions in order to obtain payment or insurance information. Hospitals may not request prior authorization from health plans before the patient has received a medical screening examination. Health plans are restricted from requiring prior authorization as well. Once it has been determined that no emergency medical condition exists or the patient has been stabilized, prior authorization can be sought.
One of the more significant elements of the revised EMTALA places responsibility for determination of the medical emergency with the examining physician and not the managed care plan. Beneficiaries are entitled to emergency services when their symptoms are of sufficient severity (including severe pain) and sudden onset, and they are acting reasonable, given their knowledge, experiences, and state of mind. It is the emergency physician who must determine if the patient meets emergency criteria and not the off-site managed care plan.
Hospitals that are designated to care for selected individuals through prearranged community or state plans are not relieved from their responsibility and obligation to comply with screening and treatment requirements of EMTALA before appropriately transferring patients to designated hospitals. Hospitals should exercise caution in complying with this provision. However, they must assure that patients do not leave the hospital prematurely at the suggestion of the hospital. In addition, when the condition is determined to be an emergency but the hospital is operating beyond its capacity, it cannot attempt to transfer the patient to another facility.
How COBRA Investigations Proceed
When investigations occur, investigators arrive at the hospital unannounced and, when allegations are confirmed during the initial phase of the investigation, the emphasis of the investigation extends to evidence of the hospital’s compliance within the last six months prior to the investigation.
To assure compliance with COBRA/EMTALA, investigators may request the following as part of the investigation process:
• The ED log for the past 6-12 months. ED logs are necessary to track the care provided to each individual who comes to the hospital seeking care for an emergency medical condition. A central log is necessary and should include patient logs from other all areas of the hospital where a patient might present for emergency services or receive a medical screening examination in addition to the ED.
• The ED policy and procedure manual. This manual should be maintained and evidence that policies and procedures are monitored and compliance assured.
• Consent forms for transfers of unstable individuals. Transfer logs for the entire hospital must be reviewed during the investigation process by examining transfers to off-site testing facilities and return; death or significant adverse outcomes; refusals of examination, treatment, or transfer; patients leaving against medical advice (AMA); returns to the ED within 48 hours; and ED visits when the patient is logged in for an unreasonable amount of time before the time indicated for commencement of the medical screening examination.
• ED committee meeting minutes for the past 12 months. These minutes provide further evidence of establishment of rules and often indicate discussions and resolution of quality issues. ED staffing schedule for physicians (past 3 months) and nurses (past 4 weeks)—This information allows the investigator to plan interviews with staff should additional information be required.
• Bylaws/rules and regulations of the medical staff. This information should support the designation of responsible parties for medical screening and policies relating to on-call physician.
• Minutes from medical staff meetings for the past 6-12 months. This information is reviewed to determine if related issues exist.
• Current medical staff roster. This may be required to identify physicians responsible for ED call.
• Physician on-call lists for past six months. As hospitals are responsible for ensuring that on-call physicians respond within a reasonable period of time, the policies governing on-call physicians are critical. Referral of emergency cases to on-call physicians in their offices is never acceptable. In all cases, the on-call physician must come to the ED to examine the patient unless the physician is in a hospital-owned facility on contiguous land or on the hospital grounds. Physicians who demonstrate a pattern of not arriving at the hospital while on-call but directing patients to be transferred to another hospital are in violation of EMTALA.Credential files to include ED director and ED physicians (optional)
• Quality assurance plan. This document should include detailed information on the steps the department will take to assure compliance with regulations
• Quality assurance minutes. These documents often indicate issues and their resolution to assure compliance.
• List of contracted services.
• ED personnel records (optional).
• In-service training program records, schedules, reports, etc.
• Ambulance trip reports and ambulance ownership information.
Professional medical review by qualified physicians following the investigation on-site is conducted to determine if:
• the screening examination was appropriate.
• evidence of an emergency medical condition existed by evaluating what could have happened to the patient if the treatment was delayed.
• there was inadequate time to provide safe transfer of a pregnant woman before delivery.
• stabilizing treatment was appropriate.
• transfer was effected through qualified personnel and medically appropriate transportation equipment.
• on-call physician’s response time was reasonable.
• the transfer was appropriate for the individual.
In general, investigators are looking for evidence of deficiencies that constitute immediate and serious threat to patient health and safety such as would prevent individuals from getting medical screening examinations and/or a lack of treatment reflecting both the capacity and capability of the hospital’s full resources. Examples of deficiency would include lack of provision of stabilizing treatment, failure of on-call physicians to respond appropriately, improper transfer, or evidence that there was a denial of medical screening examination and/or treatment to persons with emergency medical conditions as a direct result of requesting prior authorization from a managed care organization before medical assessment of the patient’s condition.
Documentation Considerations
Investigations encompass all elements of triage, screening, stabilization, and transfer of patients. As sample medical records are reviewed from cases selected from the ED log, medical records must be well-documented to clearly reflect the medically indicated treatment necessary to stabilize emergency medicine conditions, medications, treatments, surgeries, and services rendered as well as the effect on treatment of the condition of the patient or on the woman’s labor or condition of the unborn child. Medical records should also contain documentation on medically indicated screens, tests, mental status evaluations, impressions, and diagnoses supported by history, physical examination, laboratory, and other test results. According to clarifications in EMTALA, medical records of patients with psychiatric symptoms must include assessment of suicide or homicide attempt or risk, disorientation, or assaultive behavior that indicates danger to self or others.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content