that would not require an MSE What s New For any

1
EMTALA OVERVIEW

• Scientific Assembly 2003

2
Introduction

• Speakers
• Mitch Jewitt
• Linda Eynon
• Tom Barker
• Moderator
• Kathi Ream

3
Content

• On-Call Requirements
• Coming to the ED
• Applicability of EMTALA Coming to the ED for
  Nonemergency Services
• Applicability of EMTALA Hospital Inpatients
• Prior Authorization
• The New EMTALA Regulations

4
On-Call Requirements
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On-Call Requirements

• Hospitals are required to maintain a list of
  physicians who are on-call to provide treatment
  to stabilize an individual with an emergency
  medical condition
• CMS Operations Manual clarifies that hospital has
  discretion to maintain on-call list in a manner
  that meets patients needs
• Specialists not required to be on-call at all
  times, but must have policies

6
Physician Responsibility

• Often driven by medical staff bylaws and rules
• Physicians voluntarily accept EMTALA
  responsibility when they apply and accept medical
  staff privileges
• They are agents for the hospital when they are on
  call, and must follow EMTALA regardless how that
  disrupts their own private practice

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On-Call Duties

• Respond anytime they are called, when their
  expertise is needed to treat an EMC beyond the
  capability of emergency physician
• Accept patients in transfer when they and the
  hospital can provide the necessary care
• Respond in a reasonable period of time

8
On-Call Problems

• Hospitals are responsible
• Physicians have little incentive to take call
• One facility versus multiple facilities
• Small hospitals and limited medical staff
• Time spent waiting

9
ENA Recommendations to CMS

• If a hospital does not have a particular
  specialty, they should have pre-established
  transfer agreements with a hospital that has that
  specialty or subspecialty
• A specific, maximum time a patient can be held in
  the ED waiting for a specialist or for a transfer

10
Whats New

• Each hospital required to maintain the on-call
  list in a manner to best meet the needs of its
  patients.
• Physicians, including specialties are not
  required to be on call at all times. Hospitals
  must follow their PP when a specialty is not
  available or a physician cannot respond.
• There is no predetermined ratio, CMS will
  consider all factors ( of staff, demands on
  same, frequency of services hospital
  provisions).

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Coming to the ED
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Problems with Coming to the ED

• Distance and size of facilities
• Training and provider safety
• Equipment and resources
• Defining abandonment
• Hospital owned ambulances

13
ENA Recommendations to CMS

• ENA supports the prudent layperson standard for
  defining patients who seek care in the ED
• ENA has concerns about the requirement to
  response outside the dedicated ED

14
Whats New

• Patients May Present Two Ways
• Present to the dedicated ED and request
  examination or treatment
• Present elsewhere on hospital property (not part
  of the dedicated ED) and request treatment for
  what they believe to be an emergency medical
  condition

15
New Ambulance Definitions

• If the ground or air ambulance is owned and
  operated by the hospital, they have presented,
  even if not on hospital grounds
• If operated under community wide EMS protocols
  that direct where to transport, for example the
  closest facility, then the patient presents at
  that facility
• If in a nonhospital owned ambulance on hospital
  property, they have presented

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Dedicated Emergency Departments

• Any hospital department will be considered a
  dedicated emergency department if the public
  believes it as place where care is provided for
  emergency medical conditions on an urgent, non
  appointment basis
• This means an ED log and on-call requirements
• The 1/3 test

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Applicability of EMTALA Coming to the ED for
Nonemergency Services
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Non-emergency Services

• EMTALA requires that anyone who presents to the
  ED seeking medical examination and treatment must
  be given, an appropriate medical screening
  examination, by a qualified person, to determine
  if an emergency medical condition exists

19
Issues with Requests for Non-emergency Care

• Who is qualified to perform the medical
  screening exam?
• Nurses asked to perform beyond their scope of
  practice
• Patients present to the ED for routine,
  non-emergent care such as suture removal, school
  physicals, or a BP check
• Contributes to overcrowding
• Ties up already limited resources

20
ENA Recommendations to CMS

• Request the regulation state who is qualified,
  within the scope of nursing practice, as defined
  by a State Board
• Clarify outpatient services (e.g. BP check)
  performed in the ED that would not require an MSE

21
Whats New

• For any individual who comes to the ED seeking
  examination/treatment for a medical condition,
  the hospital is required to perform such
  screening as would be appropriate... to determine
  that the individual does not have an emergency
  medical condition

22
Applicability of EMTALA to Hospital Inpatients
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Hospital Inpatients

• Arguably, EMTALA was not intended to apply to
  hospital inpatients
• Expansion to hospital inpatients occurred through
  the courts
• US Solicitor General advised US Supreme Court
  that DHHS would develop regulations
• CMS proposed EMTALA apply to admitted ED patients
  until they are stabilized

24
Issues with Applying EMTALA to Hospital Inpatients

• Confusion regarding what is stable
• Unclear who the reasonable parties are to
  determine whether a patient is stable
• EMTALA has been expanded to areas is was not
  intended to apply to

25
ENA Recommendations to CMS

• Clarify what constitutes stable under EMTALA
• Define the word stable

26
Whats New

• If an individual with an emergency medical
  condition is admitted from the ED in order to
  stabilize the condition, the hospital has
  satisfied its responsibilities
• Can not admit a patient, intend not to treat, and
  then inappropriately transfer or discharge
• EMTALA does NOT apply to nonemergency hospital
  inpatients

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Prior Authorization
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Prior Authorization Requirements

• Under the regulations, hospitals prohibited from
  delaying screening/stabilization to inquire about
  patients method of payment
• CMS policy (Special Advisory Bulletin) prohibits
  prior authorization for screening/stabilization
  services

29
Issues with Prior Authorization

• CMS policy not applicable to all managed care
  organizations
• In some instances lack of prior authorization
  equates to lack of payment
• Uncertainty about when you could contact patients
  physician or insurer for additional information
• Inquire about insurance coverage during
  registration

30
ENA Recommendations to CMS

• Support the regulation that ED physicians and NPs
  are not precluded from contacting a patients
  physician for history/advice
• Endorsed including a provision which allows ED to
  seek information from insurers, excluding
  authorization

31
Whats New

• Prior authorization policies apply to hospital,
  physician and nonphysician practitioners
• Practitioners involved in patients care not
  precluded from contacting their physician to seek
  advice
• Hospitals may follow reasonable registration
  processes

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The New EMTALA Regulations
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Questions