EMTALA - Information

HCFA TAKES A POSITION ON PREAUTHORIZATION

Does obtaining preauthorization from a patient's HMO, before a screening examination, constitute a COBRA violation? HCFA has rendered its opinion, outlined in the following letter, and has begun investigations of hospitals who have required preauthorization.

Health Insurance Specialist
Linda Defeo, MD, JD
Maryland Association of Emergency Physicians
121 Cathedral Street Annapolis, Maryland 21401

Dear Dr. Defeo:

This is in response to your request for clarification on responsibilities of hospitals under 42 CFR 48924, with regard to screening patients in managed care plans who present to hospital emergency rooms requesting examination and/or treatment.

The regulation at 489.24(a) states that a Medicare participating hospital with an emergency department must provide for an appropriate medical screening examination within the capability of (its) emergency department, including ancillary services routinely available...to determine whether or not an emergency medical condition exists". Further "the examination must be conducted by individuals qualified by hospital by-laws or rules and regulations and who meet requirements of 42 CFR 482.55 concerning emergency services personnel and direction".

The only regulatory reference to insurance scams is 489.24(c)(3), "a participating hospital may not delay providing an appropriate medical screening examination...in order to inquire about the individual's method of payment or insurance status."

The patient anti-dumping law was enacted to give all individuals equal access to emergency care in Medicare participating hospitals. It follows that hospitals have the same responsibilities toward individuals in managed care plane as any other patients and are obligated by regulation to provide these individuals with an appropriate medical screening examination.

A hospital which triages a patient, then calls the patient's managed care plan for approval to further screen/treat, followed by discharge and referral to the managed care plan risk a violation of the regulation for failure to provide an appropriate medical screening examination and/or a delay in treatment.

I hope this information helps to clarify the regulation. Should you have any questions, please call me at (215). 596-6539.

Sincerely,

Rosemary Feild
Department of Health & Human Services Health Care Financing Admin.
Regional Office
P.O. Box 7760 3535 Market Street
Philadelphia, PA 18101

October 11, 1995