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This EMTALA Quick Reference Guide is intended as an abbreviated summary of what is expected of on-call physicians. It is NOT intended to be an all encompassing or comprehensive discussion of EMTALA. For more extensive information regarding requirements and obligations for EMTALA compliance, physicians and hospitals are urged to review the EMTALA statutes, relevant Centers for Medicare and Medicaid Services (CMS) EMTALA regulations, and obtain appropriate counsel from their own hospital and medical staff attorneys.
What is the Emergency Medical Treatment and Active Labor Act (EMTALA)?
EMTALA is the federal "anti-dumping law" enacted by Congress in 1986 to ensure that patients who come to hospitals for treatment of an emergency medical condition are not turned away or transferred to another facility, based on their ability to pay. It applies to any patient who seeks care, whether the patient’s access is through the emergency department or any other department of the hospital.
What are the responsibilities of hospitals and what treatment and services must be provided to be in compliance with EMTALA?
• Provide an appropriate medical screening examination to all individuals seeking emergency services to determine the presence or absence of an emergency medical condition either by a physician or other qualified medical personnel as specified in medical staff bylaws, rules and regulations, or policy and procedures.
• Stabilize the medical condition of the individual, within the capabilities of the staff and facilities available at the hospital, prior to discharge or transfer.
• Obstetrical patients with contractions are considered unstable until delivery of baby and placenta.
• An unstable patient cannot be transferred unless the patient (or a person acting on his or her behalf) requests the transfer or the transferring physician certifies in writing that the medical benefits of the transfer, outweigh the risks, and is in the best medical interest of the patient.
• Stabilize within the hospital’s capabilities to minimize the risk of the transfer.
• Obtain the acceptance of the receiving hospital.
• Send all pertinent medical records available at the time of the transfer to the receiving hospital.
• Effect the transfer through qualified persons and transportation equipment (including life support measures)
• A receiving hospital, with specialized capabilities, must accept a patient transfer unless that acceptance would exceed its capability and capacity for providing care.
• Hospitals are responsible for ensuring that on-call physicians respond within a reasonable period of time.
• The hospital must provide the name and address of any on-call physician who refused to respond or failed to make a timely response, along with the transfer records, of any patient transferred as a result of that refusal or lack of timely response.
• Prior to screening and stabilization, the hospital emergency department may follow normal registration processes, as long as they do not delay care, and prior authorization is not received before screening or commencing stabilizing treatment is allowed.
• Conspicuous signage must be posted in the emergency department stating the rights of individuals under EMTALA and whether the hospital participates in the Medicaid program; and also maintain a 24 hour/7-day (24/7) on-call schedule of physicians taking call for the emergency department.
What is an on-call list?
An on-call list is a roster of physicians providing the date and time when those physicians are scheduled to respond to the hospital to provide evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition. The on-call list must include specialists and sub-specialists routinely available to the Emergency Department. Hospitals may establish a reasonable on-call schedule other than 24/7 if they are unable to secure agreement by physicians to take call round-the-clock because of the dearth of specialists in the area.
• The on-call list is maintained by the hospital and medical staff and must be immediately updated to reflect any changes in physician staffing.
• Physicians whose names appear on the on-call list are responsible for finding a suitable replacement if they cannot be available for duty and for updating the on-call list with the replacement physician’s name and other appropriate information.
Which medical staff documents define the responsibilities of on-call physicians?
• The medical staff bylaws, rules and regulations, or policies and procedures should define the responsibility of on-call physicians to respond, examine and treat patients with emergency medical conditions.
• The medical staff and hospital should have policies and procedures to be followed when a particular specialty is not available or the on-call physician cannot respond because of situations beyond his or her control.
What are the responsibilities of on-call physicians to be in compliance with EMTALA?
• On-call physicians MUST respond to the hospital when requested to attend to patients in a timely manner and complete a medical screening examination or provide stabilizing care. CMS has not set a specific rule for response time, but some CMS officials have mentioned 30 minutes.
• The transferring physician MUST discuss the case with the receiving hospital’s authorized representative and obtain agreement to accept the patient in transfer. (All hospitals with specialized capabilities, including physician specialists, have a responsibility to accept a transfer when such transfer is necessary to stabilize an emergency medical condition .)
• On-call physicians, who may be on-call at another hospital, simultaneously, MUST NOT request that a patient be transferred to a second hospital for the physician’s convenience.
• On-call physicians who, as part of their routine responsibilities, are charged with the duty to accept patients transferred from other facilities, may not refuse any unstable transfer as long as their hospital has the capability and capacity to provide treatment.
Can an emergency patient be sent to the office of an on-call physician for the medical screening exam and stabilization?
No, not unless the on-call physician’s office is located in a hospital-owned building which is contiguous or located in a hospital-owned building that is "on campus" and the service must be billed under the hospital’s provider number.
A patient can be transferred to a physician’s office IF, the physicians’ office has specialized equipment and capability that the transferring hospital does not have. The transferring physician must certify that the medical benefits of the transfer outweigh the risks and it is in the best medical interest of the patient. Under no circumstance should a patient be transferred for the convenience of the physician.
What are the possible penalties or sanctions for EMTALA violations?
Medicare-participating hospitals and physicians found to be in violation of EMTALA could be sanctioned as follows:
• Termination of the hospital and/or physician Medicare provider agreement.
• Imposition of civil monetary penalties against the hospital with 100 or more beds of $50,000, per violation. The fine per violation for hospitals with less than 100 beds cannot exceed $25,000.
• Civil monetary penalties for physicians can be up to $50,000 per violation.
• On-call physicians responsible for examination, treatment, or transfer of an individual are subject to potential civil fines of up to $50,000 per violation for failing to come to the hospital, and may be excluded from Medicare.
• "EMTALA provides a private right of action against a hospital for an EMTALA violation. There is no private right of action, however, against a physician for violating EMTALA. Private EMTALA actions are subject to a two-year statute of limitations."
What if an on-call physician refuses or fails to show up or answer when called?
The physician’s name and address will be included in the medical record and he or she may be subject to sanctions.
Source: American Medical Association, Organized Medical Staff Section, Chicago.