EMTALA
Prepared by:
Sarah Axler, MD
University of Connecticut
Introduction
• Emergency Medical Treatment & Active
Labor Act
• Federally-mandated requirement
• Patient anti-dumping law
Objectives
• EMTALA: When? What? Whom?
• EMTALA requirements
• EMTALA exceptions
• Violations
When does EMTALA apply?
1. Individual comes to E.D. & requests
treatment
–
Regardless of ability to pay, insurance
status, citizenship, ethnicity, …
2. ‘Prudent Layperson’ Standard:
Individual’s appearance or behavior
would cause a prudent layperson to
believe that examination or treatment is
needed
What constitutes an ‘E.D.’?
• Dedicated emergency department
• Hospital property
• Ambulances
To whom does EMTALA apply?
• All Medicare-participating hospitals
• Any physician responsible for examination,
treatment, or transfer of patient in an ED
– Including physician-on-call
Photo Courtesy of U.S. Army
EMTALA Requirements
1. A hospital must perform a medical screening
exam to any person coming to ED seeking care
2. A hospital must treat any patient with an
emergency medical condition until stable, or
must transfer the patient
3. A hospital may not transfer an unstable patient
MSE: Medical Screening Exam
• Performed by a ‘qualified medical person’ (QMP)
– MD, DO, PA, NP, midwife
– Anyone defined by hospital privileges as QMP
• MSE cannot be delayed to inquire about
payment or insurance status
• Triage ≠ MSE
EMC: Emergency Medical Condition
• Definition: When absence of immediate
medical attention could result in:
– Placing health of a person or unborn child in
serious jeopardy
– Serious impairment to bodily function
– Serious dysfunction of part of the body
– Severe pain
• No EMC found?
– Hospital has no further legal obligation to treat
Pregnancy
• Pregnant women with contractions are
considered to be medically unstable
(active labor)
• QMP must certify that the patient is in
false labor
Stabilization
• Definition: Medical treatment of an EMC within the
capabilities of the facility & staff
• After stabilization, there are no further EMTALA
obligations
US Air Force / 445th Airlift Wing
Maj. Ted Theopolos
Patient Refusal of MSE or Treatment
• Inform patient of risks of refusal
• Document this conversation in the medical
record
• Attempt to obtain patient’s written refusal
On-call Physicians
• Must respond within ‘a reasonable amount
of time’ when requested
• Hospital must have policy in place for
back-up or transfer if on-call physician
cannot respond
Transfer
•
Reasons for transfer:
1. Appropriate care is not available at the
current facility
2. Patient requests transfer
•
Hospital discharge is
considered a ‘transfer’
Picture: Ed Edahl, Federal Emergency
Management Agency
Before Transfer …
1. Treat & stabilize patient as far as possible
2. Patient must sign certification / informed consent for transfer
3. Contact receiving hospital
4. Receiving hospital must accept transfer
5. Send copies of medical records & test results
6. Arrange necessary personnel & equipment for transfer
Transfer: Receiving Hospital
• Must accept transfer if hospital’s
capabilities to treat the patient exceeds
risks of transfer
• Not obligated to conduct another MSE
• Snitch Rule: Receiving hospital must
report cases of inappropriate transfers
Patient Refusing Transfer
• Inform patient of risks & benefits of
transfer
– Document conversation in medical record
• Attempt to obtain patient’s written refusal
of transfer & reason for refusal
• Continue to treat patient until stable
EMTALA Sign
• Must be posted in all public entrances, registration
areas & ED waiting areas
Enforcement
• Maximum fine per violation: $50,000
– $25,000 for hospitals with <100 beds
• Gross violations can lead to termination of
Medicare funding
• Individual doctors CAN be fined!
Take Home Points: EMTALA
• Every patient presenting to any ED must
have a medical screening exam
• Every patient with an emergency medical
condition must be stabilized and/or
transferred
• Before hospital transfer, a patient must be
stabilized as far as possible
• EMTALA is enforced with hefty fines
Conclusion
• Treat EVERY patient that comes to the ED
to the best of your ability without regard to
their ability to pay