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To better inform hospitals of their obligations under our current regulations, the Centers for Medicare and Medicaid Services (CMS) in Baltimore, MD, releases these questions and answers relating to implementation of regulations concerning the Emergency Medical Treatment and Labor Act (EMTALA, or the "anti-dumping" statute) as applied in provider-based departments.
Question: Is a hospital obligated to comply with EMTALA whenever an individual presents for emergency medical care anywhere within 250 yards of the hospital’s main building, even if the individual is in an area that is not hospital-owned and operated?
Answer: No. Generally, a hospital campus is defined in regulations as the physical area immediately adjacent to the hospital’s main buildings, other areas, and structures that are not strictly contiguous to the main buildings but are located within 250 yards of the main buildings, and any other areas determined on an individual case basis by the CMS regional office to be part of the hospital campus [42 CFR § 413.65(a)(2)]. We consider the parking lot, sidewalk, and driveway that are on hospital property to be part of the hospital for EMTALA purposes [42 CFR § 489.24(b)]. For purposes of EMTALA, the parameters of a hospital’s campus are not determined by drawing a circle 250 yards around a hospital’s main building and concluding that every building, area, and structure that happens to be located within those boundaries is part of the hospital campus.
For EMTALA purposes, an individual seeking emergency care who presents to a location on the hospital campus as interpreted above will be considered to have "come to the hospital" if a request is made on the individual’s behalf for emergency care. A hospital has no EMTALA obligation with respect to individuals who present to other areas or structures that may be located within 250 yards of the hospital’s main building that are not part of the hospital (except those areas like parking lots that serve the hospital). Examples of separate entities that are not part of the hospital for EMTALA purposes, even when located within 250 yards of the hospital’s main building, include fast food restaurants or independent medical practices.
Example: An individual comes to the office of Drs. Jones and Smith, PA, located 50 yards from Hospital A’s main building, complaining of a head cold. Drs. Jones and Smith are independent practitioners who own their practice and are not employed by, or under contract with, Hospital A. While being examined by Dr. Smith, the individual starts feeling pains in his chest. Dr. Smith suggests that the individual walk over to Hospital A’s emergency department (ED) and asks a nurse on her staff accompany the patient to Hospital A’s emergency department.
Analysis: Neither Dr. Smith, nor the office of Drs. Jones and Smith, nor Hospital A incurred an EMTALA obligation when Dr. Smith told the individual to go to Hospital A’s ED. While the office of Drs. Jones and Smith is located 50 yards from Hospital A’s main building, the doctors’ office is not part of Hospital A. However, Hospital A would incur an EMTALA obligation that begins when the individual presents at the ED and requests examination or treatment for his medical condition (the chest pains).
We note that if the situation was the same as described above, except that the office of Drs. Jones and Smith was a hospital-owned, but independently run practice, EMTALA would still not apply, unless the office of Drs. Jones and Smith was provider-based.
Example: An individual orders a meal in a fast food restaurant located two city blocks (100 yards) away from Hospital B. While waiting for his food, the individual faints and drops to the floor of the restaurant. The wait staff at the restaurant call 911 for an ambulance. When the ambulance arrives, EMS personnel begin CPR and transport the individual to Hospital B’s ED.
Analysis: Neither the fast food restaurant nor Hospital B incurred an EMTALA obligation when the individual fainted in the restaurant. The fast food restaurant is a separate entity that is not a site of any health care services that are billed under Hospital B’s provider number, even if it is located 100 yards from Hospital B. However, Hospital B would incur an EMTALA obligation that begins when the individual arrives at its ED and a request is made for examination or treatment. (7/20/2001)
Question: When is EMTALA triggered in the hospital ED and on hospital property other than in the ED?
Answer: An EMTALA screening obligation on the part of the hospital is triggered in one of two ways: first, when the individual presents at a hospital’s ED and requests examination or treatment for a medical condition. Second, when the individual presents elsewhere on hospital property (that is, at a location that is on hospital property but is not part of a recognized ED), and requests examination or treatment for an emergency medical condition.
We note that a hospital also would incur an EMTALA screening obligation if the individual was not able to make a verbal request, but showed symptoms that indicated an obvious possibility of an emergency medical condition. This policy does not require that an emergency medical condition be found, upon subsequent medical examination, to exist; rather, in the absence of a request for examination or treatment of an emergency medical condition, a prudent layperson observer, would believe, based upon the individual’s symptoms, that the individual needs emergency care.
Example: A patient comes to an off-campus provider-based outpatient department of a hospital for a scheduled physical therapy session. While undergoing therapy, the patient complains of chest pains and lightheadedness for which she requests assistance. The nurse therapist administering the physical therapy summons a nurse who has been designated by the hospital as a qualified medical person for purposes of EMTALA. The nurse screens the patient for signs of an emergency medical condition and decides that the patient must be transported to the main hospital’s ED to complete the screening examination. The nurse calls the hospital’s ED, and the patient is transported to the hospital’s ED. Her arrival is noted in that department’s central log. The patient is given a medical screening examination (MSE), which reveals that she has an emergency medical condition related to coronary artery disease. She is stabilized in the ED and is released to the care of her daughter.
Analysis: In this case, the hospital is obligated to comply with the EMTALA requirements because the patient had presented at the off-campus provider-based outpatient department and requested examination or treatment for an emergency medical condition, by complaining of the chest pains and lightheadedness. The hospital would have incurred the same EMTALA obligation if the patient had presented at a hospital department located on the main campus, rather than at the off-campus location, and requested examination or treatment for an emergency medical condition. The hospital also would have incurred the same EMTALA obligation if the patient had not made a verbal request, since her symptoms of a possible heart attack indicated an obvious possibility of an emergency medical condition. The hospital would have incurred an EMTALA obligation under these circumstances even if the patient’s symptoms were later shown to result from a non-emergency condition, such as extreme indigestion. (7/20/2001)
Question: What are the options for transporting patients from the off-campus outpatient department to the hospital’s ED?
Answer: Because the responsibility under EMTALA for the patient rests with the hospital as a whole, not merely the off-campus department, transportation to the main campus ED may be necessary. Where an individual presents to a provider-based off-campus site for examination or treatment for an emergency medical condition, the off-campus site may find it necessary to transport the individual to the main hospital’s ED to either complete the screening of the individual or to provide stabilizing treatment for the found emergency medical condition. In these circumstances, the off-campus site must arrange for appropriate transport of the individual to the hospital’s ED either by the hospital’s own transport services or by summoning an independently operated service that has agreed to provide transport for the hospital. (If the individual insists on transporting himself or herself to the hospital’s ED, the outpatient department must document the individual’s informed refusal of the offered transportation to the hospital’s ED.) (7/20/2001)
Question: If the outpatient setting is an "urgent care center/walk in" clinic that also sees patients by appointment, is it correct that only patients that present for examination or treatment for emergency medical conditions must be triaged and re-prioritized according to presenting symptoms, as would be done in the hospital ED?
Answer: Yes. However, whether in an off-campus department, an on-campus department, or a hospital ED, it is never appropriate to simply "triage" an individual who is presenting for examination or treatment for an emergency medical condition. As discussed below, the hospital (using the capabilities of the off-campus site and, as appropriate, the ED) must screen the individual presenting in this manner. We would expect that a hospital ED and the outpatient department would prioritize the screening/stabilization based upon the individuals presenting at that location. We would not expect that screening/stabilization in an outpatient department (either on the hospital campus or in an off-campus location) would be delayed for an individual because of the outpatient department’s non-emergency caseload. In instances when the appropriate staff initiate the screening and determine that an emergency does not exist, no additional treatment would be required under EMTALA. (7/20/2001)
Question: If the caseload dictates, would it be acceptable for a provider-based off-campus outpatient department to transport patients to the main campus ED to be screened?
Answer: Any transport of an individual to the main campus ED would be dictated by the individual’s need for screening and (if necessary) stabilization, not by the non-emergency caseload of the off-campus hospital department. (7/20/2001)
Question: In settings other than EDs, is the hospital responsible for noting a patient’s arrival in the ED log [42 CFR 489.20(r)(2)] and for documenting a refusal of emergency treatment [42 CFR 489.24(c)(2)] only with respect to emergency patients, i.e., those who have requested emergency medical treatment or have physical appearance/ statements that evince an emergency medical condition?
Answer: Yes. (7/20/2001)
Question: Must a MSE always be conducted in the same manner in the off-campus setting as in an ED?
Answer: In general, a MSE is the process required to reach with reasonable clinical confidence the point at which it can be determined whether a medical emergency does or does not exist. We expect that the type and extent of the screening will be dependent upon the particular conditions that the patient presents. Depending on the presenting conditions and on the capabilities and capacity available at an off-campus department, the personnel at that off-campus department may be able to complete the screening or may need to arrange transport of the individual to the main hospital’s ED for completion of the screening and any necessary stabilization.
If, after initiating the screening, the off-campus department determines that an appropriate MSE requires the capabilities or facilities available only at the main hospital, the off-campus department personnel must, in cooperation with personnel at the main hospital’s ED, arrange to move the patient to the main hospital for completion of the screening and necessary stabilizing care. If it is decided, in consultation with the main hospital’s ED, that moving the patient to the main hospital would jeopardize the individual’s life or health, the patient should be transferred according to § 489.24(d) to the most appropriate hospital or other medical facility. In those cases where it would be appropriate to activate the emergency medical services (EMS) to facilitate the transfer to the appropriate hospital or medical facility, activating the EMS does not excuse the off-campus staff from providing screening and stabilizing care within their capabilities until the EMS personnel arrive.
We note that even when the EMS is activated, the off-campus department still must contact the main hospital’s ED, notifying them of the situation. Contact may be delayed in specific cases, if the contact would endanger a patient subject to EMTALA protection. (7/20/2001)
Question: Is a hospital permitted to maintain separate on-call lists for its main campus and an off-campus department, so that physicians may agree to come in to the main campus when called, but refuse to respond to calls from the remote location?
Answer: Yes. However, if a patient is transported from the off-campus department to the main hospital ED, and a physician on the main campus on-call list is called to come in to treat the patient at the main campus, he or she is obligated to do so. (7/20/2001)
Question: Are hospitals required to adopt protocols calling for ED staff to be dispatched to an off-campus department to treat a patient, or can this decision be made on a case-by-case basis?
Answer: The preamble to the regulations indicates that hospitals may arrange to dispatch ED staff to other locations to address emergency cases. However, protocols requiring such arrangements are not required. The decision in such cases should be based on the specific situation and on the medical condition and needs of the patient. (7/20/2001)
Question: Can a hospital decline to designate any staff as qualified medical persons (QMPs) in an off-campus department routinely staffed by physicians, RNs, or LPNs, because its administrators believes the staff of that particular department would not meet its qualification requirements to serve as QMPs in the main campus ED?
Answer: No, the regulations specify at 42 CFR 489.24(i)(2)(i) that in such departments, at least one individual at the off-campus department during its regular hours of operation must be a designated QMP. (7/20/2001)
Question: In designating QMPs in off-campus departments, can a hospital use less stringent criteria than it uses for QMPs in the main campus ED?
Answer: Yes, the hospital is free to determine its own criteria for QMP designation in each setting, and the criteria for off-campus departments need not be identical to those for main campus EDs so long as the criteria are consistent with the hospital’s by-laws. (7/20/2001)
Question: What happens in circumstances where an off-campus department is only occasionally staffed by personnel who are qualified as QMPs? Can we assume that during the hours when the location is not staffed by a QMP, the location operates under the requirements applicable to off-campus departments that are not staffed by QMPs?
Answer: The requirement depends on whether the provider-based off-campus department is routinely staffed by physicians, RNs, or LPNs. If that is the case, at least one individual on duty at the off-campus department during its regular hours of operation must be a designated QMP, as described in 42 CFR 489.24(d). If the off-campus department routinely closes its office for the lunch hour, this time would not be considered part of its regular hours of operation; therefore, the designated QMP’s presence in the office would not be required during that time. (7/20/2001)
Question: What satisfies the requirement for communication between the off-campus department and the ED? Is CMS envisioning something in particular when the regulation speaks of communication between the non-emergency department site and the ED?
Answer: We have not specified the technical details of the communications link, but we believe it should be reliable for its intended purpose, which is to provide timely direction to the off-campus department. It should link the off-campus department directly to the main campus ED, and protocols should ensure that calls from the off-campus department to the main campus ED will be answered in person and responded to promptly, within the capability of the main campus ED. (7/20/2001)
Question: What is the appropriate use of Emergency Medical Services and 911?
Answer: If a patient presents to a provider-based off-campus department with an emergency medical condition, CMS expects the off-campus staff to initiate care within their capability. However, if it is evident that the staffs’ best efforts will be insufficient to stabilize the patient’s emergency medical condition, or the patient’s condition rapidly deteriorates, and the instability of the patient’s condition does not permit hospital staff to move the patient to the main hospital safely because doing so would significantly jeopardize the patient’s life or health, it would be appropriate to activate the EMS to facilitate an appropriate transfer consistent with 42 CFR 489.24(d). Activating EMS does not excuse the off-campus staff from providing screening and stabilizing care within their capabilities until EMS personnel arrive.
We note that even if the EMS is activated, the off-campus department still has a responsibility to contact the main hospital’s ED and notify them of the situation. Contact may be delayed in specific cases if the contact would endanger a patient subject to EMTALA protection. (7/20/2001)
Question: Will the decision to contact 911, transfer the patient or send the patient to the hospital-based entity’s own ED (or screen/stabilize and release on site) be evaluated for EMTALA compliance based on the capabilities of the personnel staffing the off-campus location (e.g., a receptionist vs. a physician)?
Answer: Yes. If a patient presents to the off-campus department requesting examination or treatment for an emergency medical condition, the staff should initiate care that is within the department’s capabilities while simultaneously establishing contact with the main hospital’s ED to assist the staff with determining which option is in the best interest of the patient. CMS clearly does not expect a receptionist to have the same knowledge as a nurse or a physician, but we expect the hospital to have trained and provided guidance through written protocols to its personnel as to what actions one is to implement in an emergency situation arising within that department. (7/20/2001)
Question: When a determination is made to call 911 and transfer the patient to another hospital, is it still necessary to call the main hospital ED?
Answer: Yes, the main hospital ED must be notified of the individual’s arrival and the handling of the case, so this can be noted in the hospital’s ED log. A call for this purpose should be prompt (e.g., as soon as possible after the call to EMS), but the call should not result in delay in meeting the medical needs of the patient). (7/20/2001)
Question: What is a transfer agreement?
Answer: A transfer agreement is an agreement designed to facilitate appropriate transfers. Such an agreement should be entered into between a hospital with a provider-based off-campus department and a neighboring hospital that may be a recipient of transfers, particularly where the neighboring hospital is closer to the off-campus site than the site’s main campus. We expect these agreements to establish protocols, in advance of any actual transfer, including contact information and other relevant procedures to be followed when an emergency necessitating such a transfer arises. (The policy on these agreements is specified in the regulations at 42 CFR 489.24(i)(3)(ii).) (7/20/2001)
Question: What is the expected content of these transfer agreements?
Answer: The agreements should specify [as described in 42 CFR 489.24(i)(3)(ii)] that the recipient hospital agrees to accept individuals transferred from the provider-based off-campus department of the transferring hospital when transfer of the individual is warranted, either in the case that the main hospital campus does not have the specialized capability or facilities the individual requires and the recipient hospital does, or when the individual’s condition is deteriorating so rapidly that taking the time needed for a move to the main campus ED would significantly jeopardize the life or health of the individual. The responsibilities of recipient hospitals in transfer situations are specified in section 1867(g) of the Social Security Act and in regulations at 42 CFR 489.24(e), and the agreements referred to above should make it clear that the recipient hospitals will fulfill those responsibilities. (7/20/2001)
Question: Can hospitals refuse otherwise appropriate transfers from facilities with which they do not have a transfer agreement or that fall outside the scope of the transfer agreement?
Answer: A hospital may not refuse an otherwise appropriately transferred patient if it has specialized capabilities or facilities needed by the patient as well as the capacity to treat the patient. If a hospital fails to accept a transferred patient under these circumstances, it would violate its responsibilities, as specified in section 1867(g) of the Social Security Act and existing regulations at 42 CFR 489.24(e). Note that if a hospital does not have the specialized capabilities or facilities required to provide an appropriate MSE or stabilizing treatment to a particular individual based on his or her emergency medical needs, the hospital has no obligation under 1867(g) to agree to a proposed transfer. If, however, a sending hospital transfers a patient without obtaining the consent of a receiving hospital or otherwise fails to fully comply with the requirements for an appropriate transfer, once the inappropriately transferred patient arrives on the property of a second hospital and requests emergency examination or treatment, the latter hospital is obligated under EMTALA to screen and, if necessary, to stabilize or appropriately transfer that patient. (7/20/2001)
Question: Under what circumstances can an off-campus hospital outpatient department transfer a patient to another hospital without a transfer agreement?
Answer: The regulations clearly require such an agreement to be in place. If a transfer is necessary to prevent immediate jeopardy to the life or health of a patient and a prior transfer agreement between the two hospitals is not in effect, the transferring hospital may proceed to carry out an otherwise appropriate transfer under EMTALA. The life or health of a patient should not be jeopardized simply because of lack of such an agreement. In the event of a complaint under EMTALA arising over such a transfer, however, the CMS Regional Offices will review whether the transferring hospital can document that it has made a good faith effort to secure such agreements with hospitals or other medical facilities in the area. (7/20/2001)
Question: Under the "appropriate transfer" requirements in 42 CFR 489.24(d)(2)(iii), the transferring hospital must send the receiving facility certain medical records related to the emergency condition with which the individual has presented. How does this requirement apply in the event that the transfer is from an off-campus location? For example, what if a gunshot victim walks into an off-campus hospital department, and the personnel there call 911 and administer first aid while awaiting the arrival of EMS paramedics. In such circumstances, there may be no medical record and a physician may not have made the "transfer" decision, so when the patient arrives at the receiving hospital, there is no "appropriate transfer" documentation. Is this a "patient dump" that the hospital is required to report to CMS?
Answer: The regulations cited above require any medical records for the patient to be sent at the time of transfer only to the extent that they are available at that time. Other relevant records (for example, historical records from the hospital’s files that are not readily available) should be sent as soon as practicable. Assuming records are provided (to the extent they are available) and other requirements are met, the situation described above would not be an inappropriate transfer. (7/20/2001)
Question: Will the applicability of the new regulations be determined by the cost reporting period starting date of the receiving hospital or of the transferring hospital? If the hospital doesn’t know the effective date for the transferring hospital, can it be liable if it doesn’t report the patient dump?
Answer: The effective date of the new requirements will be determined according to the cost reporting period start date of the transferring hospital. If a recipient hospital receives a transfer which it believes may be inappropriate, it should report this event to CMS regardless of whether or not it knows when the transferring hospital is first affected by the new regulations. (7/20/2001)
Question: The current interpretive guidelines regarding signage in EDs and "other places in the hospital that a person might go seeking emergency medical treatment" might be misinterpreted by some individuals to mean that all screening and stabilization must be conducted at the off-site department, without the need to move the individual to the main campus ED. Can the wording of the signs be modified to avoid confusion on this point?
Answer: The current signage requirement does not state, and is not intended to imply, that a complete emergency MSE will be conducted at the off-campus department. The hospital has a responsibility to its patients to inform them as to their rights under EMTALA. The services rendered are dependent upon the capability and capacity of the off-campus department and the hospital. Any off-campus department where patients may wait for examination or treatment for an emergency medical condition must adhere to the minimal signage requirements at the hospital according to the regulations at 42 CFR § 489.20 (q). (7/20/2001)
Question: Many EDs have removed signage that states that "payment is expected at time of service" or "co-payments and deductibles must be paid today" (or similar) as they may be deemed by a surveyor (or patient) to conflict with the signage requirements of EMTALA. In the non-ED setting, however, this is an appropriate and customary requirement. May non-ED settings continue to advise patients, through such signs, that payment is required?
Answer: Hospitals must post signs in their outpatient departments and in hospital-based entities that specify the rights of individuals under section 1867, as provided for in 42 CFR § 489.20 (q). This requirement does not preclude a hospital from posting other signs concerning payment for nonemergency care in those hospital locations. (7/20/2001)
Question: The EMTALA regulations impose various requirements on hospitals with EDs (e.g., log maintenance, arranging for transportation or transfer, forwarding medical records); is it acceptable to view these as obligations of the hospital as a whole and allow each hospital to design its own most effective way to meet the requirements?
Answer: Yes, hospitals are responsible for compliance at all hospital locations. Therefore, main hospital resources must be available to help the hospital’s off-site departments comply with these and other EMTALA requirements. (7/20/2001)