Bedside registration may be best EMTALA defense

Patient perception is key, risk officer says

Hospitals wishing to protect themselves from EMTALA-related complaints and the scrutiny follows are well advised to embrace the growing trend toward bedside registration, suggests Peggy Nakamura, RN, MBA, JD, assistant vice president, chief risk officer and associate counsel for Sacramento, CA-based Adventist Health. Joining the ongoing debate regarding interpretation of the Emergency Medical Treatment and Labor Act (EMTALA) final rule that became effective Nov. 10, 2003, Nakamura points out that the language of the rule itself is not the only factor to be considered.

In the 2003 rule, the Centers for Medicare & Medicaid Services (CMS) amended the regulations to clarify that a hospital may follow reasonable registration processes for patients covered by EMTALA. Patient registration may include requests for basic demographic information (such as name, address, and other pertinent nonfinancial information) and also may include requests for insurance status and plan membership, as long as the inquiry does not delay the medical screening or treatment.

As further stated in the EMTALA regulations, "Reasonable registration processes may not unduly discourage individuals from remaining for further evaluation." But while this language may seem to give access departments more leeway in registering patients than perhaps they had thought in the past, Nakamura stresses that it’s important to remember that EMTALA investigations and enforcement are complaint-driven. "That means they’re only coming out and evaluating [hospital EMTALA practices] when a complaint is generated," she says. "But when they do follow up [on a complaint], it opens the door to all of the EMTALA processes."

That means investigators may look at the hospital’s prior six months log of patients coming in to a dedicated emergency department (ED), and may select cases to follow through the ED experience, Nakamura notes, adding that the investigation can include interviewing patients. What makes the complaint-driven process such a crucial factor, Nakamura continues, "is that you have to consider patient perception. That’s why I believe it is difficult to defend against a patient saying, Once they started asking about my insurance — and I know I don’t have any — I knew I better get out of there.’"

"That’s discouraging the patient," she contends. "That’s the position I take, because I think we have to deal with patient perception."

California hospitals, meanwhile, must adhere to a state law that is more restrictive than the federal law, she notes. "Under a health and safety code section, we in California are specifically prohibited from collecting or inquiring about financial status prior to a medical screening exam being provided."

With all this in mind, bedside registration is the way to go, Nakamura advises. "The patient is already being evaluated by the time bedside registration starts to occur," she adds. "Because they’re in a bed, that’s the patient perception, so you’re able to [eliminate] most problems with patient perception."

HIPAA-related firings

The good news is, the access department at Community Medical Center in Fresno, CA, appears to be on top of things when it comes to ensuring compliance with the patient privacy guidelines of the Health Insurance Portability and Accountability Act (HIPAA). The bad news, notes Bret Kelsey, corporate director for patient financial services, is that he already has had to terminate three employees for accessing the hospital records of fellow employees. "We have educated and educated, so the staff know [HIPAA guidelines]," Kelsey says. "Why people think they can get away with it, I don’t know. This is something we take very seriously, as any hospital should." Complaints arose, he adds, and an investigation determined that the employees were using their access inappropriately. Other departments in the hospital have had to fire employees as well, Kelsey adds.

When it comes to handling HIPAA’s transaction code set requirements, he says, "the big thing I’m waiting for from the business office perspective is more automation, more payers sending automatic remittance advice."

"The whole purpose of the transaction code is that the hospital sends a bill, [the payer] goes in and does an inquiry and sends an electronic acknowledgement," Kelsey notes. "But with some of the claims, even though we submit it to them electronically, they don’t remit to us electronically."

While Medicare, Medi-Cal (Medicaid), and Blue Cross are remitting electronically, he adds, many others are not.

[Editor’s note: Access professionals who would like to provide feedback on these issues or any subjects related to patient access services may contact editor Lila Moore at (520) 299-8730 or]