EMTALA - Information

OIG Semi-Annual Report: May 31, 2000

The Office of the Inspector General (OIG) of the Department of Health and Human Services issued its semi-annual report detailing the activities and accomplishments of the agency for the six month period ending March 31, 2000.

Enforcement of EMTALA falls under the auspices of the OIG. The portion of the report relating to EMTALA enforcement is reproduced below, including the sampling of violations that accompanied the report.

Section 1867 of the Social Security Act (42 U.S.C. 1395dd) provides that when an individual presents to the emergency room for examination or treatment, a hospital which has a Medicare provider agreement is required to provide an appropriate medical screening examination to determine whether that individual has an emergency medical condition. If an individual has such a condition, the hospital must provide, within the capabilities of the staff and facilities available at the hospital, treatment to stabilize the condition, unless a physician certifies that the individual should be transferred because the benefits of medical treatment elsewhere outweigh the risks associated with transfer, or if the patient requests to be transferred after being advised of the inherent risks.

If a transfer is ordered, the transferring hospital must arrange for a safe transfer, which includes providing stabilizing treatment to minimize the risks of transfer, making sure the receiving hospital has agreed to accept the transfer and effecting the transfer through qualified personnel and transportation equipment. A hospital is prohibited from delaying provision of examination or treatment for an emergency medical condition to inquire about an individual’s method of payment or insurance status. Further, a participating hospital with specialized capabilities or facilities may not refuse to accept an appropriate transfer of an individual who needs those services if the hospital has the capacity to treat the individual.

The OIG is authorized to impose civil monetary penalties ( CMPs) of up to $25,000 against small hospitals (less than 100 beds) and up to $50,000 against larger hospitals (100 beds or more) for each instance where the hospital negligently violated any of the section 1867 requirements. In addition, OIG may impose a CMP of up to $50,000 against a participating physician, including an on-call physician, for each negligent violation of any of the section 1867 requirements.

Between October 1, 1999 and March 31, 2000, OIG collected $643,500 in settlement amounts from 24 hospitals and physicians. The following is a sampling of the alleged violations involved in the FY 2000 Patient Anti-Dumping Statute settlements from this reporting period.

• A small Indiana psychiatric hospital paid $30,000 to settle allegations that it failed to provide appropriate medical screenings and transfers for two patients. One of the patients had a clear emergency medical condition, but was not screened or treated because he was not able to come up with a $2,000 down payment for medical services.
• In Maryland, a small hospital settled allegations that it failed to provide appropriate medical screening examinations in a number of cases where only the patients’ vital signs were taken before they were discharged. The patients’ primary care providers had been called for payment authorization, and such authorization was denied. One patient had been kicked in the face and presented with jaw pain, missing teeth and bleeding; another patient was having difficulty breathing and sleeping, and had been vomiting. The hospital settled for $60,000.
• After a hearing, an administrative law judge imposed a $25,000 CMP on an Oklahoma hospital which refused to accept the appropriate transfer of a patient who had been critically injured in an automobile accident and required emergency vascular surgery. The transferring hospital did not have the specialized capabilities or facilities that were required to treat the life threatening injury to the patient’s abdominal aorta. After numerous calls to hospital emergency rooms and physicians, the patient was transferred to a hospital where surgery was performed in an attempt to save his life. The patient, however, died from his injuries and their aftereffects. The Oklahoma hospital has filed an appeal with the Departmental Appeals Board.
• In order to resolve allegations that it failed to provide appropriate medical screenings for several individuals, a California hospital paid $67,000 in penalties. In one case, a patient was asked to pay for services prior to being treated. In others, managed care companies denied payment authorization and/or patients were instructed to see their doctors or go to a clinic instead of being seen at the hospital. Patients presented to the hospital with conditions including multiple dog bites and pneumonia.
• A small Arkansas hospital settled an allegation that it failed to provide a 1-year old patient a medical screening examination by paying $15,000. The infant presented with a high fever and earache, and exhibited extreme discomfort when held. Two days later she was diagnosed at another hospital with bacterial meningitis. She is permanently deaf.
• A California emergency physician agreed to pay $6,000 as he allegedly inappropriately transferred a patient with a suspected intracranial bleed. Although the physician provided the patient with a screening examination after being informed the patient’s MCO had denied treatment, the patient was nonetheless inappropriately transferred in an unstable condition.
• A hospital in Florida settled, for $35,000, an allegation that it failed to medically screen a patient with new onset of diabetes mellitus. The hospital allegedly refused treatment when the patient indicated he could not make a requested deposit and, instead, referred him to a clinic or the health department for treatment the next day. Upon leaving that hospital, however, the patient immediately presented to another hospital where he was admitted and discharged 3 days later.
• An Oregon hospital paid $125,000 to settle allegations that it failed to provide several patients with appropriate medical screening examinations. The patients’ MCOs denied payment authorization for treatment. In one instance, a patient presented to the emergency room complaining that he could not move the right side of his face. Another instance concerned a 5-year old who presented with a stomachache of several days duration. The next day a pediatrician saw this child and immediately sent him to surgery for a ruptured appendix. Also, in another instance, a pregnant patient who had sharp abdominal pain went by car to another facility, without being medically screened, apparently because of insurance concerns.

  Since reviewing examples of violations is very informative, below is the list of sample cases offered from the semi-annual report of April 1, 1999 through September 30, 1999 during which time the OIG collected $1.7 million in CMP's from 61 hospitals and physicians.

• A Tennessee emergency room physician agreed to pay $15,000 to resolve one dumping allegation. The incident involved the inappropriate transfer of a gunshot victim to a trauma center approximately 30 miles away. The patient was thought to be stabilized; however, immediately prior to transfer the patient began to bleed heavily. Nonetheless, the physician transferred the patient by ambulance but without blood, even though blood was available and the patient had been prepped to receive blood. Shortly after arriving at the trauma center, the patient died from blood loss and a heart attack.
• An Illinois hospital paid $50,000 to resolve dumping allegations that six patients did not receive appropriate medical screening examinations. In five of the cases, the hospital was denied prior payment authorization by the individuals’ managed care organizations. Four of these patients, children aged 4-12, were triaged and advised to see a physician in the morning. The fifth was an 84-year old who was only triaged. In the sixth case, the emergency room physician instructed the patient to go to an urgent care center for treatment.
• A New York obstetrician/gynecologist (OB/GYN) agreed to pay $45,000 and attend and complete training on the requirements of, and the physician obligations under, the Patient Anti-Dumping Statute. This physician allegedly failed to come to the hospital, examine and treat a 19-year old uninsured pregnant patient in active labor. In addition, the OB/GYN refused to admit the patient and requested that the patient’s boyfriend drive her to another hospital rather than arrange for an appropriate transfer.
• A hospital in Kansas paid $148,000 to resolve dumping allegations that involved four burn victims. In one incident, the hospital failed to provide an appropriate transfer for a patient. The remaining three incidents involved the hospital’s failure to accept patients who needed the hospital’s specialized capabilities or facilities. Three of the four patients had out-of-state Medicaid insurance coverage.
• A Maryland hospital resolved a dumping allegation by paying $35,000 because it failed to respond to a request made for treatment of a man who collapsed outside the hospital but on hospital grounds. The man had come to the hospital with family members but went outside because he was not feeling well. After the emergency room denied two requests for assistance made by hospital security guards, a security guard was able to obtain the assistance of a doctor and other hospital personnel. The man could not be resuscitated and died.

Link to the complete Semi-Annual Report: http://www.dhhs.gov/progorg/oig/new.html