Investigations Involving Alleged Emergency Medical Treatment

5400 - Investigations Involving Alleged Emergency Medical Treatment and Labor Act (EMTALA) Violations (Rev. 18, Issued: 03-17-06; Effective/Implementation Dates: 03-17-06) Section 1866 of the Act, Agreements with Providers of Services, specifies that for a hospital, or any provider of services, to qualify for participation in the Medicare program, it must enter into an agreement with the Secretary of HHS. Effective August 1, 1986, participating hospitals with emergency departments must comply with the requirements of §1867 of the Act as a condition of their provider agreement. The following Medicare provider agreement requirements, which closely parallel provisions contained in §1866of the Act, must be met by Medicare participating hospitals with emergency departments: • 42 CFR 489.20(l) requires a hospital to comply with the requirements of 42 CFR 489.24. Section 1866(a)(1)(I) of the Act requires a hospital to have and enforce policies to ensure compliance with the requirements of §1867; • 42 CFR 489.20(m) requires a hospital to report to CMS or the SA any time it has reason to believe it may have received an individual who has been transferred in an unstable emergency medical condition (EMC) from another hospital in violation of the requirements of 42 CFR 489.24(e); • 42 CFR 489.20(q) requires a hospital to post conspicuously a sign(s) specifying the rights of individuals, under §1867 of the Act, with respect to examination and treatment for emergency medical conditions and women in labor and to indicate whether or not the hospital participates in the Medicaid program. The letters within the signs must be clearly readable at a distance of at least 20 feet or the expected vantage point of the emergency department clients. The wording of the sign(s) must be clear and in simple terms and language(s) that are understandable by the population served by the hospital; • 42 CFR 489.20(r)(1) requires a hospital to maintain medical and other records related to individuals transferred, including discharges, to or from the hospital for a period of five years from the date of transfer; • 42 CFR 489.20(r)(2) requires a hospital to maintain a list of physicians who are on call to provide treatment necessary to stabilize an individual with an emergency medical condition; • 42 CFR 489.20(r)(3) requires a hospital to maintain a central log on each individual who comes seeking assistance and whether he or she refused treatment, was refused treatment, or whether the individual was transferred, admitted and treated, stabilized and transferred, or discharged. When hospitals do not conform to the requirements of §1867 of the Act, the practice is commonly called “dumping.” A hospital with a dedicated emergency department is defined in 42 CFR 489.24(b) as a hospital that offers services for emergency medical conditions within its capacity to do so. The regulations at 42 CFR 489.24 parallel the provisions of §1867 of the Act and contain the following requirements that a hospital with a dedicated emergency department must meet: • 42 CFR §489.24(a) General. Applicability of provisions of this section. • 42 CFR §489.24(b) Definitions. As used in this section. • 42 CFR §489.24(c) Use of dedicated emergency department for non-emergency services. • 42 CFR §489.24(d) Necessary stabilizing treatment for emergency medical conditions. • 42 CFR §489.24(d)(1) General. Subject to the provisions of paragraph (d)(2). • 42 CFR §489.24(d)(2) Exception: Application to inpatients. • 42 CFR §489.24(d)(3) Refusal to consent to treatment. • 42 CFR §489.24(d)(4) Delay in examination or treatment. • 42 CFR §489.24(d)(5) Refusal to consent to transfer. • 42 CFR §489.24(e) Restricting transfer until the individual is stabilized. • 42 CFR §489.24(e)(1) General. • 42 CFR §489.24(e)(2) Appropriate transfer to another medical facility. • 42 CFR §489.24(e)(3) Provides whistleblower protection to physicians and qualified medical personnel. • 42 CFR §489.24(f) Recipient hospital responsibilities. • 42 CFR §489.24(g) Termination of provider agreement. • 42 CFR §489.24(h) Consultation with Quality Improvement Organization (QIO). • 42 CFR §489.24(i) Release of QIO Assessment. • 42 CFR §489.24(j) Availability of on-call physicians. • 42 CFR §489.24 (j)(1) On-call list. • 42 CFR §489.24 (j)(2) Hospital on-call policy and procedures. If a hospital fails to meet these requirements, CMS may terminate the provider agreement in accordance with 42 CFR 489.53. The Office of the Inspector General (OIG) has the responsibility and authority to assess civil monetary penalties (CMPs) or to exclude physicians from the Medicare program when a hospital or physician violates these requirements. Additionally, individuals suffering personal harm and medical facilities suffering financial loss as a result of a violation of these provisions can bring civil action against the offending hospital and physicians. Filing for such civil action is limited to a period of 2 years after the date of the alleged violation. This legislation does not preempt any State or local laws, except to the extent that State or local requirements directly conflict with a requirement of this legislation.