Overview & Keys to Compliance

Congress enacted the Emergency Medical Treatment and Labor Act (EMTALA) in 1986 as part of the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985. This law, originally referred to as the “anti-dumping act,” was designed to prevent hospitals from transferring (or dumping) uninsured or Medicaid patients to public hospitals without  providing a medical screening examination to ensure  the patient was stable for transfer. I

Today, the Act continues to impact physicians, advanced practice clinicians (APCs) and hospitals nationwide in a number of ways. Compliance is especially important for clinicians providing emergency care and the emergency department (ED) to ensure both quality and safety for patients and the hospital.

Mike Lipscomb, M.D., ApolloMD Chief Quality & Patient Safety Officer and Regional President, shares an overview of EMTALA, keys to compliance, challenges and what ApolloMD is doing.

What do we know about EMTALA?

  • EMTALA is triggered when a person presents to the dedicated emergency department, or is on “hospital property,” and requests care.
  • MSE or treatment cannot be delayed to inquire about an individual’s method of payment, ability to pay or health insurance status.
  • EMTALA requires clinicians to provide an MSE, determine if an emergency medical condition (EMC) exists and stabilize or, if the patient cannot be properly stabilized, provide an appropriate transfer.
  • The Act’s obligations end when a patient is seen, screened and admitted for hospital services, when a patient is appropriately transferred, when no emergency medical condition exists or when a patient has been offered a screening exam and informed of the risks but refuses treatment.
  • Should a provider violate the requirements, penalties may result in a combination of fines for the provider and hospital, or termination from Medicare.

What does EMTALA define as an emergency?

EMTALA classifies an emergency medical condition as follows;

An emergency medical condition is defined as.

  1. a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) 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 the woman or her unborn child) in serious jeopardy,
    • serious impairment to bodily functions, or
    • serious dysfunction of any bodily organ or part; or
  2. 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 transfer may pose a threat to the health or safety of the woman or the unborn child.

If a patient presents with a severe or possibly life threatening emergency, the emergency medical condition must be stabilized or, if unable, approved for immediate transfer to a location which can offer the medical services needed. Additionally, if a pregnant woman presents with an emergency medical condition, she must be treated until delivery or until a transfer is appropriate under the statute.

How can I avoid an EMTALA violation?

EMTALA compliance can change in many different situations and sometimes causes confusion, as the violations are not always clearly defined. The easiest way for a physician to get “burned” is by not having enough education or awareness of the law in its entirety. Paying attention to the details when treating a patient is important to ensure no violations are conducted. Clinicians, or medical directors, should try to keep up with current cases and outcomes to share and key takeaways and findings as a department.

When in Doubt, Conduct an MSE

Cases get especially unclear when law enforcement is involved. A few examples of confusing situations include:

  • An individual is brought in by law enforcement. The individual becomes disorderly and violent. The officer demands to take the patient to be incarcerated. If the patient has not received the proper MSE to determine if an emergency medical condition exists and the clinician releases the patient to the officer, the clinician may be in violation of EMTALA. If a MSE has been performed and no EMC exists, then the clinician has met its EMTALA obligations and no further actions are necessary.
  • An individual is brought to the ED by a law enforcement personnel who requests a blood alcohol test and does not request an examination or treatment for a medical condition. If the average individual would not believe the person needed such examination or treatment, the hospital is not obligated to provide an MSE to the individual under the Act’s requirements. However, if the individual in custody was involved in an accident or sustained injury to themselves, an MSE would be warranted to determine if an EMC exists.
  • This principle also applies to sexual assault cases where the main purpose of presentation to the ED is for the gathering of evidence.

Document, Document, Document

Violations are also commonly seen with incomplete or improper documentation of an individual’s paperwork. The physician may have provided all of the appropriate care consistent with EMTALA requirements, but then failed to adequately document his or her actions. Missing a blank on an EMTALA mandated form would fall into this category. In some cases, it is later discovered documentation is deficient. At this point, the physician must correct the record through proper late entry protocols.

“If it is not in the chart, it didn’t happen,” is an important rule of thumb and compliance reminder for clinicians. This guidance also applies to refusal of treatment and transfer. While a signed written refusal is optimal, the noncompliant patient will not always willingly sign a form. In these cases, physician documentation is paramount. As long as your team properly documents every step, then there is little room to call for an EMTALA violation.

Our Approach

At ApolloMD, we strive to educate and re-educate each and every physician and advanced practice clinician in our organization. The best approach is preventing any potential violation in the beginning. ApolloMD offers annual EMTALA training to provide the most up-to-date information, current challenges and relevant cases. All clinicians and clinical operations team members have access to the ApolloMD Quality Corner, a database of healthcare quality information used as an educational resource for all clinicians.

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