An ED patient is admitted, but then is transferred almost immediately. This kind of situation can call into question whether the admission was “good faith” or if the hospital was just trying to work around federal EMTALA requirements.

“Any scenario where a patient is admitted, when it is clear that the hospital does not have the appropriate inpatient services that could be reasonably expected to stabilize the patient’s emergency medical condition, could be questioned as a good faith admission,” says Mary C. Malone, JD, a partner at Hancock Daniel in Richmond, VA.

Usually, suspect cases are those in which patients are transferred shortly after admission. “Like most other healthcare situations, the documentation of medical decision-making becomes key,” Malone says.

Investigators will want to see evidence that shows an admission was made with the intent of providing stabilizing treatment within the hospital’s capacity and capability at the time the decision to admit was made. Problematic cases involve questionable admissions — those for which the hospital lacked the capacity and capability to provide the needed stabilizing treatment.

“However, to the extent that the patient’s condition unexpectedly worsens soon after admission and a transfer is necessitated, that should not create issues with the good faith nature of the initial admission,” Malone notes.

Good documentation shows the medical judgment used in the initial decision to admit and the reason for the unanticipated need to transfer. To avoid problems with EMTALA good faith admission requirements, the chart should be clear on the reason for admitting the patient in the first place, as opposed to just documenting the reason for transferring the patient.

A recent case makes this clear. The plaintiff sued the hospital for an alleged EMTALA violation, claiming the facility just admitted the patient to meet EMTALA requirements with no intention to treat — and then immediately transferred the patient elsewhere.1

The court ruled there was no evidence the hospital improperly admitted the patient. “As the court pointed out, the plaintiff did not show any facts to establish that the intent of the admission was to avoid providing EMTALA-mandated care,” says Stephen A. Frew, JD, vice president of risk consulting at Johnson Insurance Services and a Rockford, IL-based attorney.

The plaintiff alleged the hospital could have provided better care or could have transferred him sooner. “Those issues are malpractice-type allegations, not EMTALA liability issues,” Frew notes. The court had ruled against the plaintiff on the issue of inadequate screening under EMTALA. “The bad faith admission theory appears to have been an attempt to maintain an EMTALA theory of liability for a tactical legal advantage, instead of reverting to a malpractice cause of action,” Frew observes.

In the early days of EMTALA, some hospitals would try to work around the regulation by admitting the patient. The on-call specialist would try to manage the patient later by phone, or would enter a phone order to transfer without ever responding to the bedside. “Hospitals thought they could avoid making the on-call specialist come in,” Frew explains.

Some patients received little or no actual care during the period of admission, and either died or were transferred without care.

“This further complicated the situation, because a number of hospitals felt they did not have to accept transfers of admitted patients,” Frew says. In recent years, Frew has not seen this practice of bad faith admissions intended to avoid EMTALA compliance. Still, there are situations where the patient is admitted and deteriorates, so a transfer becomes necessary.

“But these are the exact situations where the good faith admission rule is meant for — to avoid EMTALA liability,” Frew adds.


  1. Williams v. Dimensions Health Corp., No. 18-2139 (4th Cir. 2020).