EMTALA Case Referral to OIG

5480.2 - EMTALA Case Referral to OIG (Rev. 18, Issued: 03-17-06; Effective/Implementation Dates: 03-17-06) CMS refers appropriate cases to the OIG for investigation. Periodically, OIG will advise us of the criteria they would prefer CMS to use in referring cases. Examples of the types of cases that may be referred include: 1. Financial Screening - The hospital and/or responsible physician refused to examine or treat a person based on the person’s insurance status or inability to pay a fee. The financial basis for the decision must be clearly supported by evidence in the file, e.g., documented policy, interview reports. 2. Patient with Trauma or Acute Emergency Condition - The hospital and/or responsible physician (including an on-call physician who failed to come to the hospital) failed to screen, stabilize, or appropriately transfer (or, in the case of a hospital with specialized capabilities or facilities, refused to accept an appropriate transfer of) a person with trauma, e.g., a severe head injury, or other acute emergency condition, e.g., heart attack or stroke, requiring immediate and substantial medical intervention. 3. High Risk Event (such as Birth) Occurs Prior to Arrival at Another Hospital - The hospital and/or responsible physician discharged or refused to screen/treat a person who gave birth (or is subject to another high risk medical event) prior to arriving at another hospital (especially if transport is by private vehicle). 4. Death or Serious Harm Results from Dump - The evidence in the file (including the QIO Review) demonstrates that the dumping violation caused serious medical harm or death to the victim of the violation. 5. Egregious Violation Prioritized by CMS - CMS concludes that a CMP is appropriate because of the seriousness of the violation (the person must have had an emergency medical condition) and other relevant factors, e.g., long history of noncompliance, hospital policy resulting in violations, pattern of serious violations, knowing and willful violation. This category is for those cases that CMS determines are very serious and merit a CMP but do not fit within other categories identified by OIG.