EMTALA. Santa Rosa Memorial Hospital Medical Staff May 9, 2017

Transcription

1 EMTALA Santa Rosa Memorial Hospital Medical Staff May 9, 2017

2 Reflection "Your success in life isn't based on your ability to simply change. It is based on your ability to change faster than your competition, customers and business." Mark Sanborn It is not the strongest or the most intelligent who will survive but those who can best manage change. Charles Darwin "Never doubt that a small group of thoughtful, concerned citizens can change the world. Indeed it is the only thing that ever has. Margaret Mead

3 Agenda Agenda Items Reflection EMTALA Primer Satisfying EMTALA Obligations Transfers Reporting Obligations Penalties Recent Broadening of EMTALA Liability Summary Questions

4 EMTALA Primer EMTALA stands for Emergency Medical Treatment and Labor Act. Federal law enacted in 1986 that requires anyone coming to dedicated emergency department be stabilized and treated, regardless of their ability to pay or insurance status. Stabilization requires that such medical treatment of the condition be provided as may be necessary to assure, within reasonable medical probability, that no material deterioration of the individual's condition is likely to result from the transfer (including discharge) of the individual from the facility.

5 EMTALA Primer cont. Applies to Medicare-participating facilities that offer emergency services. Does not require 24/7 coverage for every specialty hospital just needs to have a back-up plan (usually stabilize to capability and transfer) in event of an emergency. Hospitals, including critical access, must provide medical screening examination (MSE) when a request is made for examination or treatment for an emergency medical condition (EMC). EMC is defined as a medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could be reasonably expected to result in: (i) placing the health of the individual in serious jeopardy; (ii) serious impairment to bodily functions; or (iii) serious dysfunction of any bodily organ part.

6 EMATLA Primer cont EMC is also includes a pregnant woman who is having contractions and in active labor. Qualified medical person must perform the initial MSE -- typically is physician. Non-physician providers can perform the MSE, but must be formally designated in Medical Staff Bylaws or Rules and Regs. Examination and treatment cannot be delayed to inquire about methods of payment or insurance coverage. EDs must post signs notifying patients and visitors of right to a MSE and treatment of EMCs.

7 Satisfying EMTALA Obligations Hospitals must maintain a list of physicians who are on-call. Hospitals must have policies addressing unavailability of certain specialists and physicians. On-call physician must respond within a reasonable amount of time as specified in the Medical Staff Bylaws and Rules and Regs. On-call physicians can consult with other physicians on the phone, video conferencing or other means without violating EMTALA. However, if physician is on the on-call list, and has been requested by treating physician to appear, and fails or refuses to appear in a reasonable time, then the on-call physician may be subject to sanctions for violating EMTALA.

8 Transfers Hospitals with specialized capabilities (burn units, trauma designation, NICU, etc.) are obligated to accept transfers from hospitals who lack the capability to treat unstable emergency medial conditions if the receiving hospital has the capacity to treat the individual. Two components: The individual must require the specialized capabilities of the receiving hospital, and The receiving hospital must have the capacity to treat the individual.

9 Transfers cont Specialized Services Element If a transferring hospital has an individual with an emergency medical condition, and the individual does not require any treatment beyond the capabilities or facilities available at the transferring hospital, the receiving hospital is under no obligation to accept the transfer. Example: Hospital A has a fully staffed and equipped emergency department with specialty on-call physicians available. Hospital B is a Level 1 trauma center. Hospital A receives two individuals who were in a motor vehicle accident and who both require the services of a thoracic surgeon due to internal injuries. Hospital A has thoracic surgeons on-call and has the capability within its own emergency department to treat the individuals. Analysis: Hospital A has the staff and capability to treat and stabilize the individuals. Hospital B, therefore, has no obligation to accept the transfer even if it has the capacity to do so.

10 Capacity Element Transfers cont Capacity is not only determined by the hospital's current number of patients in a specialized unit, number of staff, or available equipment. If the hospital, is able to, or has in the past, addressed occupancy issues by moving patients within the hospital, calling in additional staff, and borrowing additional equipment from other facilities, then the hospital may be able to provide services to patients in excess of its specialized occupancy limit.

11 Transfers cont Capacity Element Example: Example: Hospital A has a 10 bassinet neonatal intensive care unit that is currently full. In the past, Hospital A has accommodated a capacity of 15 neonates by relocating ventilators and other equipment to its children's medical floor and providing additional staff to monitor the bassinets. Hospital B had a woman in labor present to the hospital, however, Hospital B does not have an obstetrical department. However, it does have the capability to deliver a baby. Once the baby and placenta are delivered, it is determined that the baby is in distress and requires that specialized services of a hospital with an NICU. Hospital B contacts Hospital A to initiate an appropriate transfer. Analysis: In this situation, Hospital A is required to accept the transfer because the infant requires the specialized services of Hospital A and Hospital A has demonstrated in the past its ability to provide services beyond the capacity of its NICU.

12 Transfers cont If hospital admits an individual as an inpatient for further treatment, its EMTALA obligation ends. EMATLA also does not apply to inpatient transfers between hospitals or transfer of stable patients. Under EMTALA, a hospital can transfer an unstable patient under the following conditions: A physician certifies the medical benefits expected from the transfer outweigh the risks; OR A patient makes a transfer request in writing after being informed of the hospital's obligations under EMTALA and the risks of transfer.

13 Transfers cont A hospital can also transfer an unstable patient if the transfer is an appropriate transfer. An appropriate transfer involves numerous factors, such as: (1) the transferring hospital must provide ongoing care within its capability until transfer occurs to minimize risks; (2) provide copies of medical records; (3) must confirm that the receiving facility has space and qualified personnel to treat the condition and has agreed to accept the transfer, and (4) the transfer must be made with qualified personnel and appropriate medical equipment.

14 Reporting Obligations EMTALA enforcement is complaint driven. Receiving hospitals are required to report to CMS or State survey agency promptly when it suspects it received an improper transfer. Notifications must occur within 72 hours of the incident. Failure to report improper transfers may subject receiving hospital termination of its provider agreement. Receiving hospital can report on any issue, but it is only required to report if it thinks it received an improper transfer. Example If a hospital refused to accept a patient based on insurance coverage, even though it is technically an EMTALA violation, that reporting is not mandatory.

15 Penalties Termination of the hospital or physician s Medicare Provider Agreement and exclusion from Medicare and Medicaid programs. Civil Monetary Penalties on hospital or physicians. Up to $50,000 ($25,000 for hospitals with fewer than 100 state-licensed and Medicare-certified beds) for each violation, adjusted for inflation. Civil actions for personal injury against hospital. A receiving facility, having suffered financial loss as a result of another hospital's violation of EMTALA, can bring suit to recover damages.

16 Recent Broadening of EMTALA Liability Office of Inspector General (OIG) CMP rule, effective January 6, 2017, clarifies liability guidelines for Civil Monetary Penalties (CMP) for EMATLA violations. CMP rule affirms that government only has to show negligence of hospital for EMTALA obligation and not willful conduct.

17 Recent Broadening of EMTALA Liability cont CMP rule amends the mitigating and aggravating factors government will use to determine hospital or physician's liability under EMTALA: Removes "intent to leave" as a mitigating factor. Adds "corrective action" as a mitigating factor. Adds "risk of patient harm" as an aggravating factor.

18 Recent Broadening of EMTALA Liability cont Removes "intent to leave" as a mitigating factor. Through its enforcement activities, the OIG found that the fact a person may have "demonstrated a clear intent to leave" was not a proper mitigating factor on the hospital's liability. The OIG reasoned that the clear intent to leave may have been based on the hospital's failure to properly screen the individual, which should not lesson the hospital's liability. Adds "corrective action" as a mitigating factor. Situations in which a hospital takes appropriate and timely corrective action in response to a violation will be considered a mitigating factor. However, the corrective action must be completed prior to CMS initiating an investigation. Adds "risk of patient harm" as an aggravating factor. The previous regulation required the OIG to prove actual patient harm. Noting that "this formulation is overly constrained," the new CMP rule adds risk of patient harm, which includes premature discharge or the need for additional services.

19 Summary Knowledge and understanding of EMALTA obligations is important. Documentation is critical. Without proper documentation, the government will presume proper examinations, stabilizing treatment, or transfers either never happened or were not done properly. Proactive efforts to comply with EMTALA can significantly reduce the risk of the hospital and the physician incurring EMTALA liability and penalties in the future.

20 Questions