Answers to five common questions about COBRA
ED Nursing asked experts for answers to five common questions on COBRA/EMTALA (Consolidated Omnibus Budget Reconciliation Act/Emergency Medical Treatment and Active Labor Act) requirements. Here are answers to keep you out of trouble with the Health Care Financing Administration (HCFA).
1. Can you complete the medical exam in the hospital’s outpatient clinic? Often, nurses wrongly assume that it’s okay to send a patient to an outpatient clinic next door to the ED, as opposed to a physician’s office 10 blocks away. To refer a patient to an off-site clinic, you must complete the medical screening exam, discharge the patient, and fulfill the appropriate transfer requirements, says Charlotte Yeh, MD, FACEP, chief of emergency medicine at New England Medical Center in Boston and member of HCFA’s task force on EMTALA.
Your screening process must be non-discriminatory. "You cannot screen people away based on their financial status—you may only screen based on medical criteria," says Yeh. "You can send all patients who present with a rash and no fever to the dermatology clinic on hospital premises, and they will see all comers who meet that criteria. That may be permissible, but you can’t send all managed care patients to that clinic."
2. What brings reviewers into your backyard? All reviews begin with a complaint—from either a patient, a hospital, or EMS. Every hospital is mandated by law to report suspected violations from other hospitals, such as inappropriate transfers. "If it even crosses their mind that it might be inappropriate, the hospital is required to report it." says Stephen A. Frew, a Rockford, IL-based health care attorney and consultant. At least one hospital has been cited for nonreporting, he adds.
3. Who can perform a medical screening exam? Any non-physician has to be credentialed to perform a medical screening exam by the hospital. "There’s nothing that says a non-physician can’t perform the exam, but it has to be clearly recognized by the institution that this person has the background, experience and training to do it appropriately," Yeh explains. Still, that recognition doesn’t get the facility off the hook. HCFA doesn’t have to agree with the hospital’s decision about who is appropriate, she notes.
4. What if patients want to seek care outside the ED? Some patients may want to leave the ED when they find out their treatment won’t be covered by insurance. "You can’t make somebody stay. If the patient says, I’m leaving to see my regular doctor, that’s their prerogative," says Janie Sims, RN, BSN, nurse clinician at University Hospital’s ED in Augusta, GA. Still, ED nurses need to be careful not to say anything that could be interpreted as encouraging patients to leave.
"If a patient wants to go elsewhere because they find out their insurance won’t pay and refuses a medical screening, the patient should sign a refusal form," says Yeh. "You are required to inform the person of the risks and benefits of that refusal."
5. How should you discuss insurance with the patient? It’s risky to discuss insurance with the patient before the medical screening exam is completed—even if the patient brings it up. "There should never be an implication that the hospital provided financial information as a deterrent for emergency care," Yeh stresses. "Technically speaking, the patient should not be finding out that their insurance won’t pay before the medical screening exam is completed."
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