Do your contracts violate EMTALA?
A special advisory bulletin was published to emphasize that no managed care contract can supersede a hospital’s duties under the Emergency Medical Treatment and Labor Act (EMTALA), says Charlotte Yeh, MD, FACEP, medical director of Medicare Policy at the National Heritage Insurance Company in Hingham, MA. "So the message is for hospitals to be sure that their contracts are in compliance," she explains.
The bulletin, issued by the Washington, DC-based Office of the Inspector General and the Baltimore-based Health Care Financing Administration, clarifies that your obligations under EMTALA remain, regardless of any contracts with managed care organizations (MCOs). Managed care contracts that require prior authorization are in direct conflict with EMTALA requirements, and those type of contracts still are being signed, says Yeh.
In recent months, there has been a movement away from ED prior authorization, Yeh says. EMTALA is one reason for that, she says. "There is also the growing consumer backlash, patient protection legislation at the state level, and the fact that access to emergency services with the prudent layperson definition is a fairly well supported concept at the bipartisan level and certainly on a consumer level." All those factors have led to lessening of prior authorization for emergency services, Yeh explains. "But the issue has certainly not gone away, and EDs must remain vigilant."
Be careful about who is handling your contracts with MCOs, warns Caral Edelberg, CPC, CCS-P, president of Medical Management Resources, a Jacksonville, FL-based emergency medicine coding and consulting firm. "One of the more significant problems I run into with audits is when uninformed hospital personnel are given the responsibility to negotiate managed care contracts," she says. "Under no circumstances should these contracts be developed or signed without review and approval of ED staff and hospital attorneys."
Many managed care contracts reviewed directly violate federal law, Edelberg reports. "In addition, coders and business office personnel should be educated about EMTALA provisions and trained to spot problems as they manage claims each day," she says.
Hospitals and ED should provide informational brochures or informational packets for patients and insurers to educate them, she recommends. "The hospital will need to take the lead in notifying the public and the insurers of their rights and obligations." For example, hanging signs in the ED that state patients have a right to a medical screening exam and stabilization treatment regardless of their ability to pay would be helpful, she suggests.