EMTALA Training Slides

1. Emergency Medical Treatment
and Active Labor Act
(EMTALA)
Elizabeth Schwartz Corn
Hall Booth Smith, P.C.
40 Calhoun Street, Suite 550
Charleston, SC 29401
Email: ecorn@hallboothsmith.com
Phone: (843) 720-3460

2. Disclaimer:
• This training session covers EMTALA on a basic level.
• No comments should be considered to be legal advice to
any individual participant.
• No attorney-client relationship is created with any
individual person by this presentation alone.
• EMTALA is a fact-sensitive area of law and any change
in facts may change the legal analysis.

3. Emergency Medical Treatment and Active Labor Act
EMTALA is a federal law that governs when and
how a patient may be refused treatment or transferred to
another hospital. It is also known as the patient "anti-
dumping" law and was enacted to protect uninsured or
indigent patients from being turned away based on their
inability to pay.

4. When is EMTALA triggered?
When a person:
• Presents to the Dedicated Emergency Department,
or is on "hospital property," and
• Requests care.
A request for care can be made on a person's behalf or, if
the person is unable to make a verbal request, it is enough to
trigger EMTALA if the person shows symptoms that indicate an
obvious possibility of an emergency medical condition.

5. Hospital Property
Hospital Property includes:
• The main hospital campus,
• Parking lot,
• Sidewalk,
• Driveway, and
• Other areas or structures within 250 yards of the main hospital
building.
Hospital Property does NOT include:
• Other areas or buildings that are not part of the hospital,
• Physician offices (or entities that participate separately in
Medicare), or
• Restaurants, gift shops, or other non-medical facilities.

6. Obligations
• Provide a medical screening examination
• Determine if an emergency medical condition exists
• Stabilize or, if cannot stabilize, provide an appropriate
transfer

7. What is a medical screening examination?
An appropriate medical screening is a screening conducted by
qualified medical personnel and conducted within the capabilities of the
ED, including ancillary services routinely available, to determine if an
emergency medical condition exists.
"Qualified medical personnel" includes physicians and any other
individuals determined qualified by the hospital bylaws or rules and
regulations.
Generally, a screening will be considered appropriate if the same
screening is done of all individuals regardless of ability to pay.

8. Emergency Department
Any department or facility of the hospital (even if not on main
campus) that is:
• Licensed by the State as an Emergency Department, or
• Held out to the public as providing emergency care (by name,
posted signs, or advertising), or
• Provided at least 1/3 of its outpatient visits for the treatment of
emergency medical conditions during the preceding year.
EMTALA does not apply to off-campus facilities not providing
urgent or emergency care on a regular basis (even if operated under the
same Medicare provider #).

9. No Delay in Examination or Treatment
• Cannot delay medical screening examination or treatment to
inquire about the individual's method of payment or insurance
status
• Cannot seek prior authorization from insurance company until
after screened
• Can contact the individual's physician for consult, so long as the
consult does not inappropriately delay services
• Can follow reasonable registration procedures (it's okay to ask if
insured and by whom), BUT procedures cannot delay screening
or treatment and cannot intimidate the person

10. What is an emergency medical condition?
A medical condition manifesting itself by acute symptoms of
sufficient severity such that the absence of immediate medical attention
could reasonably be expected to result in:
• Placing the health of the individual (or unborn child) in serious
jeopardy; or
• Serious impairment of bodily functions; or
• Serious dysfunction of any bodily organ or part.
An emergency medical condition exists if a pregnant woman is
having contractions and there is inadequate time to transfer before
delivery.
Severe symptoms can include pain, psychiatric disturbances
and/or symptoms of substance abuse.

11. When do EMTALA obligations end?
• When a patient is seen, screened and admitted for hospital services
• When a patient is appropriately transferred
• When no emergency medical condition exists
EMTALA does not apply to patients – only non-patients. Once a
person is admitted and becomes a patient, EMTALA obligations no
longer apply. EMTALA does not apply if a person is already a patient.
For example, if a person comes to the hospital's outpatient lab for routine
services and while there has an emergency medical condition, EMTALA
obligations are not triggered.
A person cannot be admitted to the hospital in bad faith to get
around EMTALA obligations.

12. When is an individual stabilized?
When no material deterioration of the condition is
likely, within reasonable medical probability, to result from or
occur during the transfer of the individual from the facility.
A woman in labor is considered stabilized upon
delivery of the child and the placenta, or, after a reasonable
time of observation, is certified by a physician to be in false
labor.

13. Transfer
The movement (including the discharge) of an individual
outside a hospital’s facilities at the direction of any person
employed by (or affiliated or associated with) the hospital.
Transfer does not include movement of an individual who
(1) has been declared dead, or (2) leaves the facility without
permission.

14. How to transfer?
If an emergency medical condition has not been stabilized, cannot
transfer unless:
• The individual requests the transfer in writing and has been
informed of EMTALA obligations and the risks of the transfer,
• Physician Certification that the transfer benefits outweigh the risks
(summary of risks and benefits specified), or
• Qualified Medical Personnel Certification if no physician is on-site
and the QMP consults with the physician regarding the benefits
and risks and the physician later signs,
AND
• An appropriate transfer is available.

15. What is an Appropriate Transfer?
• The transferring hospital provides treatment (within its
capability) that minimizes risks, and
• The receiving facility has the space and the qualified
personnel for the treatment and agrees to accept the
transfer, and
• The transferring hospital sends all pertinent medical
records available at the time of transfer, and
• The transfer occurs with qualified personnel and
transportation equipment.

16. Emergency Medical Conditions
and Mental Health
A mental health emergency may qualify as an emergency
medical condition under the language of EMTALA.
Psychiatric Emergencies would include an individual:
• Expressing suicidal or homicidal thoughts, or
• Determined to be dangerous to self or others.
Examples of Psychiatric Emergency Medical Conditions:
• Depression and Suicidal thoughts;
• History of suicide attempt and bipolar disorder with c/o feeling
depressed;
• History of assaultive or self-mutilating behavior.

17. Individuals with Mental Health Issues
• Must be screened for both physical and mental emergency
condition.
• The screening for a mental condition typically consists of
questions and answers, monitoring and de-escalation
techniques.
• A psychiatric patient is stable for discharge or transfer
when he is no longer a threat to himself or others and can
be managed on an outpatient basis.

18. Intoxicated or Impaired Patients
Intoxicated patients are typically unstable until sober.

19. Individuals in Police Custody
Police officers often request medical clearance for people
in custody prior to transport to jail.
If the individual in custody requests stabilizing treatment
and continuing care is indicated, but the officer will not allow the
patient to stay:
• Document efforts to convince the custodian to allow
screening and treatment.
• If unsuccessful in efforts, request that the officer sign the
patient out AMA.
• Document the refusal of treatment.

20. Refusal of Exam or Treatment
A hospital has met the requirements of EMTALA if:
• The patient is offered further medical examination and
treatment,
• The patient is informed of the risks and benefits of the
offered exam and treatment, and
• The patient refuses to consent to the exam or treatment.

21. Documentation of Refusal
Document:
• Description of exam/services refused.
• Secure refusal in writing.
• The document to be signed by the patient should
include that the patient has been informed of the
risks and benefits of examination and treatment.

22. Signage Requirements
EMTALA requires all hospitals to post a sign
conspicuously in any emergency department or in a place
likely to be noticed by all individuals entering the ED that
specified the rights of individuals under EMTALA with
respect to examination and treatment for emergency
medical conditions and women in labor and indicates
whether the hospital participates in the Medicaid program
under a State approved plan.

23. Records Requirements
EMTALA requires that hospitals:
• Maintain medical and other records of all individuals
transferred from or to the hospital for five years.
• Maintain a list of physicians who are on call for duty after
the initial examinations to provide stabilizing treatment.
• Maintain a central log on each individual who comes to the
ED seeking assistance and whether he refused treatment,
was refused treatment, was transferred, admitted and
treated, stabilized and transferred, or discharged.

24. Penalties for Violations
• Termination from Medicare
• $25,000 or $50,000 fines for hospitals with
100 beds
• Up to $50,000 fine for an MD
• Adverse publicity
• Malpractice liability
• Potential private right of action

25. Ambulances
• EMTALA applies when a non-patient is in a hospital owned
ambulance, even if it is not yet on hospital grounds.
• When a non-patient is in a non-hospital owned ambulance, EMTALA
applies when the ambulance presents at the ED (EMTALA does not
apply if radio contact only and no physical presentation).
• EMTALA does not apply if the hospital owned ambulance is under
community-wide EMS protocol that directs the ambulance to another
hospital or if the ambulance is directed by a non-affiliated physician.
• Even if the ED is on diversionary status, EMTALA applies if the
ambulance shows up anyway.