When alerting to urgent care copay, beware of risk
Question: We have a freestanding urgent care clinic affiliated with our hospital; but one insurer won’t recognize it as an urgent care center, pand those insured patients must pay an emergency department copay instead of an urgent care copay. We’ve had incidents in which patients became irate after treatment when they were informed that they had to pay the higher copay, so we’d like to place a sign up front explaining the situation. But would that violate EMTALA by discussing financial information before screening the patient? What can we say on the sign without discouraging patients from seeking treatment? (And in general, when and how does EMTALA apply to urgent care clinics?)
Answer: You may be risking more trouble with EMTALA than the original problem is worth, warns Kerrin Slattery, JD, a partner in the Chicago office of McDermott, Will & Emery LLP. She says that, while she sympathizes with the desire to alert patients to the unexpected copay amount, a sign in the entrance area may create a bigger problem by creating misunderstandings that could prompt an EMTALA investigation.
First, Slattery explains that EMTALA usually applies to urgent care clinics. Urgent care clinics are subject to EMTALA if they are a department of the hospital and they meet the definition of a "dedicated emergency department," she says. A dedicated emergency department is defined as meeting any of these three criteria: It is licensed as an emergency department, or it is held out to the public as providing urgent care without scheduled appointments, or at least a third of the clinic’s patients come in without a scheduled appointment. Typically, an urgent care clinic qualifies under the second or third criteria.
So assuming the urgent care clinic is covered by EMTALA, the question is whether you would violate the law with a sign that warns patients of a particular insurer’s requirement that the emergency copay applies instead of the lower copay for urgent care. The law allows providers to perform any reasonable admission procedures, but it prohibits any action that would unduly discourage an individual from staying to receive treatment.
"Does signage warning that the patient will have to pay more money here unduly discourage?" Slattery asks. "In a perfect world, EMTALA was not intended to restrict good patient service, which is what you’re trying to do here. You’re trying to help the patient avoid a nasty surprise later with the copay. But the reality of what happens might be different."
Slattery says trouble could arise from even a generally worded sign like "This is not a licensed emergency department; however your insurer may consider services rendered here as emergency services." Patients reading that sign are likely to ask questions of your admissions staff such as "Does my insurer charge more if I’m treated here?"
"I think the sign could elicit questions, and then you’re really starting to jeopardize EMTALA compliance," Slattery explains. "It all depends on how the staff answers those questions, which might never have been asked but for the sign you put up. It’s not necessarily the sign itself that poses the risk but the conversation that is prompted by the sign."
Any statement by the staff that is construed as discouraging the patient from staying for treatment could be seen as an EMTALA violation. And the risk is high even if your staff are very careful about how the copay information is relayed. Consider this scenario:
The staff may explain the facts and encourage the patient to stay for treatment, but the patient may respond that "If I have to pay the $100 emergency copay, I might as well be in an ED." At the ED, the patient mentions that the urgent care clinic staff said he would have to pay a $100 copay, so he came to the ED instead. After hearing that a few times, the ED staff wonders if that is an EMTALA violation they are obligated to report. To cover themselves and avoid charges that they did not report a violation, they pass their concerns on.
The next thing you know, regulators at your door investigating whether you are steering patients away from your urgent care clinic.
No one wants that. Slattery suggests that the problem you’re trying to fix — the occasional patient who becomes irate upon learning of the higher copay — is not worth the risk of the EMTALA violation.
"You might be better off by dealing with it at the billing desk after treatment. Explain it to them there, and if you have someone upset about it, deal with them individually," she says. "Otherwise, you get on a slippery slope by trying to address everyone up front."
Any statement by staff that is construed as discouraging a patient from staying for treatment could be seen as an EMTALA violation.
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