By: Dave Davidson
In 1986 President Ronald Reagan signed the Emergency Medical Treatment and Active Labor Act (EMTALA) into law. Since then, the application of the law has been expanded and refined. It was one of the first laws giving the government the authority to dictate certain operations of a hospital. While other laws and regulations such as the Anti-Kickback Statute and the Stark Law have become more of a focus for health care providers, EMTALA remains an area of active enforcement. All providers with hospital privileges should therefore be aware of its application.
The policy behind the law is fairly straightforward. Hospitals with emergency departments should not be able to turn away patients needing care because of their inability to pay (no more “wallet biopsies” as part of triage). Likewise, hospitals should not be able to “dump” patients on other facilities for reasons other than for advanced care.
The requirements of the law are also very basic. If a patient comes to an emergency department and requests an examination or treatment for a medical condition, the hospital must provide an appropriate medical screening exam, within its capability, to determine whether or not the patient has an emergency medical condition. The screening provided goes beyond simple triage, and must be performed by a clinical provider such as a physician, nurse practitioner, or physician’s assistant.
The focus of the screening is to identify a possible emergency medical condition, which is defined as a medical condition, manifesting itself by acute symptoms of sufficient severity, such that the absence of immediate medical attention could result in:
– Placing the individual’s health (or the health of an unborn child) in jeopardy;
– Serious impairment to bodily functions; or
– Serious dysfunction of any organ.
Active labor is also considered an emergency medical condition, as is the existence of pain as the only symptom.
If a patient does not have an emergency medical condition, the hospital’s EMTALA obligations end. The hospital will likely still treat the condition, such as giving an antibiotic or applying a bandage. However, no other actions are required under EMTALA.
If there is an emergency medical condition, the hospital is required to provide treatment to stabilize the patient’s condition. In other words, the hospital must do everything within its capability to make sure the patient’s condition does not get worse. That could mean surgery, interventional procedures, medical treatment, or admission. The requirement is not to “cure,” but to “stabilize.”
There may be times that the hospital and its physicians do not have the capability to fully stabilize and treat a patient. A badly burned patient, or a sick baby are classic examples. In those situations, EMTALA allows a hospital to transfer the patient to get the appropriate level of care. Obviously the patient must be stable enough to tolerate the transfer, and informed consent must be obtained, but a transfer is permitted. The propriety of the transfer should be clearly documented, and the EMTALA requirements apply to the receiving hospital as well.
Although the law itself refers specifically to emergency departments and hospitals, the application is very broad. The hospital’s obligations apply to any patient on its campus who is seeking care. For example, if a patient mistakenly walks into the hospital gift shop and asks for care, the gift shop staff have the responsibility to get the patient to the emergency department. The fact that the patient is not physically in the emergency department does not relieve the hospital from its duties.
EMTALA also applies to on-call physicians. Most screenings can be adequately performed by the emergency room providers. However, severe conditions will need a specialist. A telephone call may be all the ED physician needs. However, if the emergency department asks the on-call doctor to come in, EMTALA requires the physician to comply. The standard of care may allow for treatment to be provided at a later time (such as waiting to perform surgery until swelling has gone down), but if the emergency department requests help during the stabilization process, the on-call physician must go in to help.
EMTALA enforcement is serious. Fines up to $50,000 per occurrence can be levied against the hospital and providers. Disciplinary actions can be taken against the licenses of the hospital and the providers involved. Corrective action may be initiated by the hospital medical staff. Hospital accreditation can be put at jeopardy, and most seriously, everyone involved runs the risk of suspension or exclusion from the Medicare program, which is effectively the death penalty for any facility or practitioner.
Providers who receive a subpoena or other notice that they are subject to an EMTALA investigation should take immediate steps to retain experienced counsel to guide them through the process. Obviously no one should speak about the case directly with investigators without legal counsel. Hospitals and medical staffs that are developing EMTALA policies or are investigating possible compliance errors need to be well advised to ensure they understand the law and take steps towards a proper process or resolution.
The policy behind EMTALA is clear. Its application is very broad, and the consequences of a violation are severe. Its provisions should therefore always be in the mind of hospital staff and providers as they deal with patients possible suffering from emergency conditions.