Can EMTALA apply to the same patient twice?
Question: A patient is treated in your ED and discharged. Subsequently, the family is unhappy with the care that the patient received and brings him back to the ED. Does the second ED visit incur a second round of obligations under EMTALA, even if there is no actual emergency? If yes, does a patient actually have to physically leave the ED and then return for EMTALA to apply? What if the patient remains in the waiting area after treatment and then asks to be examined again?
Answer: The short answer is "yes" to all of those situations, according to James Mitchiner, MD, MPH, a practicing emergency physician and Medicare medical director at MPRO, Michigan’s federally designated Quality Improvement Organization (QIO), where he conducts EMTALA reviews on behalf of the Centers for Medicare & Medicaid Services (CMS).
In Mitchiner’s opinion, the deductive logic behind the answer is more important than the answer itself. When the EMTALA statute was first written in 1985, it was assumed that it was so simple and concise that no regulations would be needed to guide those who were responsible for following it, he says. This, of course, turned out not to be the case, so initial EMTALA "regulationsguidelines" were issued in 1994 by the Health Care Financing Administration (HCFA, which later became CMS) and updated by CMS in November 2003. According to Mitchiner, the regulations do not explicitly address individual clinical situations such as that presented above, so one has to rely on a careful reading of the statute to answer the questions.
EMTALA is triggered whenever an individual satisfies two criteria: 1) comes to the ED; and 2) makes a request (or has a request made on his or her behalf) for examination or treatment of a medical condition. Note that the request is connected simply to a medical condition, as opposed to an emergency medical condition, which is what the EMTALA-mandated medical screening examination is supposed to check for. So, did this individual come to the ED the second time? The answer is clearly "yes" for all the above situations. And did he (or the family) make a request for examination or treatment of a medical condition on the second occasion? Again, the answer is "yes." The fact that he came back to the ED a second time, even on the same day or even during the same hour, as well as the fact that he did not have an actual emergency, is irrelevant to whether EMTALA applies, notes Mitchiner. Each presentation to the ED must be considered on its own merits, regardless of the preceding circumstances or the chief complaint registered at the time of triage.
The answer to the second question in this case — does a patient actually have to physically leave the ED and then return for EMTALA to apply — is "no" in Mitchiner’s opinion. In other words, the statute does not excuse a hospital from any additional EMTALA obligations simply because the patient did not physically leave the premises. And, to answer the third question, Mitchiner feels that EMTALA would still apply to each and every request for examination or treatment, even if such a request was essentially a representation to the triage desk from the ED waiting room for the same or a different complaint.
In addition, Mitchiner says that these two visits could be viewed from the standpoint of EMTALA’s antidiscriminatory nature. If you have two ED visits, by what rationale would you apply EMTALA only to the first ED visit but not to the second? What would make someone think, prior to evaluating the individual a second time, that the initial visit was more "legitimate" than the subsequent one, or that the individual was not equally deserving of a subsequent independent EMTALA benefit equivalent to that of the first? Clearly, fairness would mandate that disparate temporal applications of the law not be allowed, Mitchiner says.
Question: A patient is treated in your ED and discharged. Subsequently, the family is unhappy with the care that the patient received and brings him back to the ED.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