EXECUTIVE SUMMARY
Warning patients about long wait times, or failing to log them in, are common registration practices, and both are potential violations of the Emergency Medical Treatment and Labor Act.
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Never collect a copay or deductible before the medical screening examination.
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Implement bedside registration when possible to avoid treatment delays.
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Do not attempt to collect payment, even if it would not delay treatment, until after the stabilizing treatment has been provided.
“You are welcome to wait, but it may take the doctor several hours to get to you. We won’t be nearly this busy in the morning!”
Such comments made by a well-meaning emergency department (ED) registrar could be interpreted as encouraging a patient to leave, in violation of the Emergency Medical Treatment and Labor Act (EMTALA).
“It is not uncommon for hospitals to be cited for failure to provide a medical screening examination and stabilizing treatment due to comments made by a registrar,” says Gina Greenwood, JD, an attorney at Atlanta-based Baker Donelson.
These violations often come to light after a neighboring hospital files a complaint, after receiving a patient who presents due to a long wait time at the previous facility. “I have seen cases in which an individual presents to the hospital ED, then quickly decides to seek care elsewhere because a registration staff member or a security guard mentions the long wait time or otherwise steers a patient away from the hospital,” says Greenwood.
She also has seen EMTALA violations alleged because registrars failed to log in patients. “Registration staff need to understand the gravity of the words that they use when communicating with patients,” says Greenwood.
There are ways to communicate and inform patients of long wait times without steering patients away from the hospital, she emphasizes. “If the patient asks about the wait, staff can certainly respond, but should not in any way indicate to the patient that the hospital is too busy to care for the patient,” says Greenwood.
DON'T DELAY TREATMENT
ED registrars should never collect a copay or deductible when the patient arrives, warns Sue Dill Calloway, RN, JD, president of Patient Safety and Healthcare Consulting and Education in Dublin, OH. Dill Calloway is also vice president of risk and patient safety at Auburn, CA-based Emergency Physicians Insurance Exchange Risk Retention Group.
“This can never be done before the medical screening is done and the patient is determined to be stable,” advises Dill Calloway. Otherwise, the hospital is at risk for violating EMTALA.
The medical screening exam and/or stabilization treatment should never be delayed to inquire about payment status or the patient’s insurance. “This does not mean that hospitals cannot follow reasonable registration processes,” says Dill Calloway. She says registrars should follow these practices:
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Once the patient is triaged or brought to a treatment room, ED registrars can obtain basic information such as name, chief complaint, and primary care physician.
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Registrars can ask for an insurance card, demographic information, and who to contact in case of an emergency. “There can be no prior authorization from managed care,” says Dill Calloway.
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Registrars can obtain authorization for payment and services only after the medical screening exam is done and the patient is stabilized.
EMTALA was intended to be an antidiscrimination statute, notes Greenwood, and it primarily was created to prevent emergency patients presenting to the ED from being refused care because the patients were indigent and/or uninsured. EMTALA has been expanded through the years.
“Of the numerous EMTALA violations that I have defended, ironically, the violations defended rarely have been related to the actual discrimination of patients because of inability to pay,” says Greenwood.
However, to avoid even the appearance of doing something wrong related to the uninsured, hospital staff members often wait to obtain basic registration information or consent forms until after the patient has been stabilized. “In reality, EMTALA does not prohibit a hospital from maintaining normal registration and consent processes,” says Greenwood. However, EMTALA guidance makes it clear that hospitals may not delay examination and/or treatment in order to ask about the individual’s insurance or payment, she says. Greenwood recommends these steps:
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Use bedside registration when possible to avoid treatment delays.
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Don’t try to collect payment, even if the collection would not delay treatment, until after the patient is medically screened and stabilized.
“The key is not to delay treatment due to anything related to money or insurance,” Greenwood emphasizes. (See related stories later in this issue on EMTALA violations involving ED registration and on EMTALA-compliant registration processes.)
SOURCES
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Sue Dill Calloway, RN, JD, Emergency Physicians Insurance Exchange Risk Retention Group, Auburn, CA. Phone: (614) 791-1468. Email: [email protected].
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Gina Greenwood, JD, Baker Donelson, Atlanta. Phone: (404) 909-0665. Email: [email protected].
