EMTALA Update

Boil Down EMTALA Interpretive Guidelines For ER Staff

Give key hospital staffers a Cliff Notes version of HCFA's 1998 interpretive guidelines on the Emergency Medical Treatment and Active Labor Act (EMTALA) and then train them to implement those requirements in light of a recent report from the HHS Inspector General's office.

The interpretive guidelines are the driving force of the state survey process, in which state surveyors are deputized by HCFA to inspect hospitals for alleged EMTALA violations. "They have taken on a quasi-legal authority," says attorney Lowell Brown. "People out there who want to comply ought to know what the interpretive guidelines are."

EMTALA requires hospitals to screen and stabilize patients before transferring them to another hospital - and before asking them how they will pay for care. Violations are punishable by Medicare termination and/or civil monetary penalties.

The new OIG report reveals the results of a survey of emergency department personnel - including emergency physicians, nurses, registration staff and on-call specialists - about their knowledge of EMTALA's requirements. While the majority knew EMTALA's basic requirements, many staffers don't know about the more detailed aspects of the law and its interpretive guidelines.

For example, the OIG says 80% of ER staffers know hospitals must post patients' rights signs in the ER and keep a log of ER visits, but fewer than 70% knew you must hold onto transfer records for five years and can't retaliate against employees who decline to approve illegal transfers or report EMTALA violations.

Although 90% of ER directors get information routinely about EMTALA, it's very rarely directly from HCFA. The OIG says that may be why 65% of ER directors know about the guidelines. Only 27 of those surveyed were aware that the OIG and HCFA published an EMTALA advisory bulletin in November 1998. That bulletin gives hospitals guidance on EMTALA compliance, including ways to address managed care plans' insistence on preauthorization despite EMTALA's ban on letting insurance issues get in the way of screening and stabilizing the patient.

The problem is, the guidelines are so detailed. Brown says the best way to convey the key points to staff is to conduct in-service training on the requirements. For example, EMTALA says hospitals have to provide medical screening exams before transferring patients or asking about insurance and the guidelines very specifically define the parameters of a medical screening exam. But ER staff needs a user-friendly definition.

ER Staffers Need Training

Other OIG findings and their implications:

-- Only about one-quarter of on-call specialists got EMTALA training. "If that's true, that's a violation waiting to happen because a lot depends on on-call physicians cooperating," Brown says. "Probably the more physicians understand the law, the more they will be willing to comply - if they understand how much risk they expose themselves to" by failing to appear when summoned for an emergency in their specialty.

-- Training really works. The OIG said registration staff who received EMTALA training were much less likely to ask patients inappropriately for insurance information. About two-thirds of ER physicians, nurses and registration staff have been trained in EMTALA. The busier an ER is, the less likely its staff gets training.

-- ER staff want clearer definitions of key terms, such as "emergency medical condition" and "stable for discharge." Brown says hospitals must develop their own policies that employees can understand. 'The law is confusing, but you have to decide how to implement it and comply with it, and then give people clear direction."

-- Hospitals have a hard time staffing mandatory on-call panels consisting of specialists who can do medical screening exams and provide stabilizing treatment to ER patients.

In terms of solutions, the OIG suggests more direct HCFA-OIG education efforts to ER doctors and staff, such as direct e-mail notification to hospitals.