3 0 + Years of EMTALA Providing Emergency Care Under Federal Law: - PDF document

EMTALA Primer by Todd B. Taylor, MD, FACEP ED Director's Academy – May 2, 2019 – Dallas, TX Who Am I?  Former ACEP Council Speaker  Board Certified Emergency Physician  EMTALA Compliance Consultant  Former Vice-President for Public Affairs Arizona College of Emergency Physicians 3 0 + Years of EMTALA  Providing Emergency Care Under Federal Law: EMTALA - 2001 Medical Staff & On-Call Physician Obligations  18 Years Attending Emergency Physician – Phoenix, Arizona Banner Good Samaritan Regional Medical Center  8 Years as EMTALA Consultant Arizona QIO Health Services Advisory Group  Emergency Physicians’ Monthly Contributing Editor & Editorial Advisory Board EMTALA Q & A Editor EMTALA Resources Download free at: www.acep.org/library/pdf/emtalaSupplement.pdf "Bible of Practical EMTALA Compliance" (newly updated) Highlights of legal developments & regulatory changes, along with accumulated enforcement information since the 1986 inception of EMTALA. Narrative summary & most recent version of federal site review guidelines for EMTALA compliance. “Flash card" reviews of individual EMTALA compliance topics, the real world application, necessary compliance documentation, & cautions on common compliance issues. www.medlaw.com www.medlaw.com/faq.htm 1

EMTALA Primer by Todd B. Taylor, MD, FACEP ED Director's Academy – May 2, 2019 – Dallas, TX Additional Information Send e-mail request to: ttaylor@acep.org Specify what you want: The Advisory Board Company  PDF of lecture slides The Watergate, 600 New Hampshire Ave., N.W. Washington, D.C. 20037  PDF of handout Phone: (202) 266-5920  Anything else, please be specific Fax: (202) 266-6550 E-mail: orders@advisory.com Web Site: www.advisory.com Burgeoning EMTALA Issues The real issue > Enforcement  Health plan (ACA) network transfers (CMS proviso)  Does not matter what we think it means  Deferral of Care (“Screen & Street”)  Opioid pain medication policy  Only matters what CMS\OIG says it  ED “Appointments” means & how they enforce it  Continued on-call issues (exacerbated by ACA)  Often a disconnect between what  Psych boarding & lack of inpatient services central CMS says & how it is enforced  EMTALA training requirement in the field (Regions)  Observation services (when does EMTALA end?)  Civil courts add additional complexity  Telemedicine  Documentation of declined transfers & confusion  Stand alone EDs & hospital owned urgent care  Regionalization of services  Transfer for diagnostic services only Basic EMTALA Requirements  Three statutory requirements regarding “individuals” who “come to the hospital” & request medical care: 1)The hospital must conduct an appropriate medical screening examination (MSE) to determine if an emergency medical condition (EMC) exists. 2

EMTALA Primer by Todd B. Taylor, MD, FACEP ED Director's Academy – May 2, 2019 – Dallas, TX Basic EMTALA Requirements Emergency Medical Condition 2) If the hospital determines that an emergency (A) a medical condition manifesting itself by acute medical condition exists, it must either - symptoms of sufficient severity (including severe a) provide the treatment necessary to stabilize pain) such that the absence of immediate the emergency medical condition or medical attention could reasonably be expected b) comply with the statute's requirements to to result in-- affect an “appropriate transfer” of a patient (i) placing the health of the individual (or, with whose condition has not been stabilized. respect to a pregnant woman, the health of the A hospital is considered to have met this second requirement if an individual refuses woman or her unborn child) in serious jeopardy, the hospital's offer of additional examination (ii) serious impairment to bodily functions, or or treatment, or refuses to consent to a (iii) serious dysfunction of any bodily organ or transfer, after having been informed of the risks and benefits. part; 42USC1395dd (e)(1)(A) Basic EMTALA Requirements Basic EMTALA Requirements 3) If an individual's emergency medical condition has  Non-physician certification requirements: not been stabilized, the hospital may not transfer If a physician is not physically present when the the individual unless transfer decision is made, a qualified medical (a) the individual or his or her representative person may sign the certification after the makes a written request for transfer to another physician, in consultation with the qualified medical facility after being informed of the risk of transfer and the transferring hospital's medical person, has made the determination that obligation under the statute to provide the benefits of transfer outweigh the increased additional examination or treatment; or risks. However, the physician must later (b) a physician signed a certification summarizing countersign the certification. the medical risks and benefits of a transfer and certifying that, based upon the information available, the medical benefits reasonably expected from the transfer outweigh the increased risk. Transfers Transfer of “Stable” Patients  “Appropriate” Transfer  EMTALA does not apply to “stable” patients  “the movement of an unstable patient with an as defined in 42USC1395dd (e)(3)(B) emergency medical condition”. Definitions:  Five elements must be documented: 1) Provide treatment within its capability The term “stabilized” means, with respect to an (including on-call specialists) to minimize the emergency medical condition described in health risks to the patient until transfer. paragraph (1)(A), that no material deterioration 2) The receiving hospital must have space & of the condition is likely, within reasonable qualified personnel to accept the transfer. medical probability, to result from or occur during 3) The receiving hospital must agree to accept the transfer of the individual from a facility, or, the transfer & to provide appropriate treatment. with respect to an emergency medical condition 4) Qualified personnel/equipment are used during described in paragraph (1)(B), that the woman the transfer. has delivered (including the placenta). 5) Send & document all relevant medical records, radiographs, etc. were sent with the patient. 3

EMTALA Primer by Todd B. Taylor, MD, FACEP ED Director's Academy – May 2, 2019 – Dallas, TX Transfer by POV EMTALA Compliance Principles Is it ever acceptable to send a patient  Applies to Medicare participating hospitals by private car?  Anyone who presents in any way to any where on hospital property & in any way  Yes, if patient is “stable” or “stable requests medical attention should be taken for discharge” to the appropriate area of the hospital (i.e.  No, if “unstable” &/or requires ED, OB triage, psychiatric triage etc.) for a monitoring MSE & necessary stabilizing treatment.  Routine collection of demographic &  “Safest” is to always send insurance information is allowed as long “transfers” by ambulance as it does not impede the patient receiving a MSE & stabilizing treatment. EMTALA Compliance Principles EMTALA Compliance Principles  Hospitals that have the capacity must  Patients may not be coerced into being accept appropriate transfers from facilities transferred (i.e. “your insurance will not that do not have the capacity to provide pay for your visit”) or seeking medical necessary care for patients: care elsewhere even if required by their insurance. 1) Without consideration of insurance status 2) Regardless of nationality or state/county  EMTALA is an “Anti-Discrimination Law”: of residence Patient must be treated the same regardless 3) Regardless of complaint of socioeconomic status 4) Regardless of closer appropriate hospital 1) With or without insurance 5) Regardless of the sending facility’s non- 2) Regardless of nationality, race, creed, religion compliance with EMTALA 3) Regardless of complaint “New” (2003) EMTALA Regs Overview EMTALA Compliance Principles  EMTALA applicable only in “dedicated” ED  EMTALA documentation should be & not the inpatient setting completed on any patient not  Depends on which “door” you enter otherwise being routinely discharged with care completed*:  Formalizes more flexible language for on- call specialists 1) Certification For Transfer  Specialists can be on-call at more than one hospital simultaneously 2) Request For Transfer  Can schedule elective procedures while on-call. 3) Consent To Transfer  Basic requirements unchanged *Technically only required for “unstable” patients,  MSE w/o delay but stability may be questioned retrospectively.  Stabilization  “Appropriate” transfers 4