Physicians' obligations under EMTALA

Some examples explain the Emergency Medical Treatment and Labor Act (EMTALA).


Hospitals participating in Medicare must comply with the Emergency Medical Treatment and Labor Act (EMTALA) statute. This is commonly known as the “anti-dumping law” and was enacted in 1986.

Even though the law has been around for many years, many physicians don't fully understand their individual obligations and liability under it. The hospital, as well as the individual physician, is subject to a civil monetary penalty for each separate EMTALA violation. Physician fines go up to $50,000 per violation ($25,000 at a hospital with fewer than 100 beds). These monetary penalties are not covered by professional liability insurance and are the physician's personal responsibility. If the violation is gross or is repeated, physicians may be excluded from participation in Medicare and state health programs.

Photo courtesy of Dr Dontaraju
Photo courtesy of Dr. Dontaraju

Thus, it's important for every physician in the hospital, including hospitalists, to understand the law's requirements. As the chairman of the department of medicine at an institution receiving many transfers from nearby community hospitals, I have seen how imperative it is for all our physicians to comply with the EMTALA obligations.

Anyone who comes to the ED requesting an examination or treatment should undergo appropriate medical screening by a qualified medical provider to determine if the individual has an emergency medical condition (EMC). If a patient has an EMC or is in active labor, he or she should be given stabilizing treatment or an appropriate transfer if the hospital does not have the capability or capacity to stabilize the individual.

Examination or treatment should not be delayed to inquire about the individual's insurance or payment status. Also, any participating hospital is required to accept appropriate transfers if the receiving hospital has specialized capabilities not available at the transferring hospital.

Geographically, the law includes patients not only in the ED but also on hospital property, including the main hospital campus, parking lot, sidewalk, driveway, and any building owned by the hospital within 250 yards of the main hospital campus. Ground or air ambulances can be hospital property if they are hospital-owned and -operated.

An appropriate medical screening examination must be conducted by a physician or qualified medical personnel. A physician is ultimately responsible for screening done by a nonphysician clinician. The medical screening exam involves a brief history, physical examination, diagnostic tests, and procedures. It is an ongoing process, beginning with triage but typically not ending there.

So, what is an EMC? It is any condition manifested by acute symptoms of sufficient severity (including severe pain), in which the lack of immediate medical attention would place the health of an individual or unborn child in serious jeopardy or cause serious dysfunction of bodily organs or serious impairment to bodily functions. Stabilizing treatment is defined as treatment provided to a patient that leads to resolution of the EMC.

What is an appropriate transfer? The patient should be stable for transfer. The treating physician should have determined that no deterioration is reasonably likely to occur during or as a result of the transfer between facilities. Hospitals may transfer unstable patients at their request if they have been informed of the risks of transfer and the hospital's EMTALA obligations, or if a physician determines that the benefits of the transfer outweigh the risks.

Obviously, these definitions leave room for physicians to interpret them differently. The following patient scenarios may help illustrate the use of the statute.

Case 1

A 60-year-old woman presents to a community hospital ED with hematemesis shortly after midnight. The ED physician suspects acute variceal gastrointestinal bleeding and requests to admit the patient under the hospitalist service. The hospitalist calls the on-call gastroenterologist to come and evaluate the patient. The gastroenterologist says he is tired and has a full day of procedures tomorrow. He says, “If the patient is that ill, you need to send her to the university hospital,” then hangs up.

In this case, the gastroenterologist is on call and if he can treat variceal bleeding and has the hospital privileges for the procedure, then he is clearly violating the EMTALA by not doing so. Not only the hospital but the on-call gastroenterologist is subject to civil monetary penalty and sanctions.

If a physician is listed as on call and is asked to make an in-person appearance to evaluate and treat an individual with an EMC, the physician must respond in person in a reasonable amount of time. EMTALA applies to consulting and admitting physicians as well as ED physicians.

Case 2

A 75-year-old woman with stage 4 chronic kidney disease is dismissed by Nephrologist A from his practice because of lack of payment and no-shows. This patient is now being followed by Nephrologist B from a competing medical group. Tonight, she presents to the ED not feeling well along with nausea and vomiting. Evaluation reveals end-stage renal failure and hyperkalemia not responding to standard treatment. The ED physician calls Nephrologist A (listed as on call for the hospital). He replies back saying, “I am on call for my group only, and besides, I am not going to come at 11 p.m. to see a patient I dismissed from my practice.”

In this case, Nephrologist A may be in violation of EMTALA and subject to penalty and sanctions.

If a physician is on call for a hospital, that means she or he is an on-call doctor for the hospital, not for her or his group alone. Exceptions include hospitals with physicians from competing groups on call for the same specialty at the same time, so all physicians should familiarize themselves with the call structure at their hospitals.

Case 3

A 45-year-old man presents to a rural hospital's ED with acute respiratory failure secondary to a flare-up of interstitial lung disease. The ED physician requests a transfer to a tertiary hospital for a higher level of care. The on-call physician at the tertiary hospital refuses, saying that there are other, closer hospitals that should be called instead.

If the larger institution has empty beds and is capable of taking care of the patient, the transfer should be accepted. The on-call hospitalist who said the patient should be transferred to another hospital may be found to be in violation of EMTALA.

Refusal to accept a valid transfer from another hospital is an EMTALA violation. There is no EMTALA rule stating that the closest facility must be contacted for transfer.

Case 4

A 62-year-old man presents to the ED of Hospital A with acute chest pain, and acute coronary syndrome is suspected. Hospital A has the capacity to treat the patient. The ED physician, however, calls the on-call hospitalist at Hospital B and wants the patient to be admitted to Hospital B (located in a different state). His reason for transfer is that his hospital does not accept the patient's state medical insurance card and Hospital B does.

The ED physician may be found in violation of EMTALA as he has identified an EMC and it is not clear if the EMC is stabilized. If the transfer were to occur, the on-call hospitalist might also have violated EMTALA.

Insurance should never be a part of risk/benefit consideration for a transfer. Not reporting an inappropriate transfer is itself an EMTALA violation. If a patient is inappropriately transferred, it needs to be reported to CMS within 72 hours.

Case 5

A 44-year-old man is brought to the ED of a community hospital after a brief cardiac arrest from which he was successfully resuscitated. He is diagnosed with acute ST-elevation myocardial infarction. Telemetry reveals ventricular ectopic beats. The ED physician calls the nearest university hospital to transfer him.

The patient clearly has an EMC and will be in an unstable condition when he is transferred because his potential to deteriorate en route is high. However, this is acceptable under EMTALA, because the small hospital lacks the resources to fully stabilize the patient.

The medical screening examination should be clearly documented, along with stabilization efforts and a physician certification that the medical benefits expected from the transfer outweigh the risks. In addition, the transferring hospital must provide ongoing care within its capability until transfer to minimize transfer risks; it must also provide copies of medical records, and the transfer must be made with qualified personnel and appropriate medical equipment.

Conclusion

These cases highlight the importance of every hospital physician's understanding and utilizing EMTALA appropriately. I highly recommend that hospital leaders provide EMTALA education to residents, fellows, and new physician recruits. Department chairs may also need to evaluate their individual physicians' compliance with EMTALA from time to time and provide the necessary training and resources.