Access Management Quarterly

AMs still unclear about stabilization vs. triage

Access managers continue to debate the intricacies of the Emergency Medical Treatment and Labor Act (EMTALA), despite the publication of an EMTALA final rule on Sept. 9, 2003 by the Centers for Medicare & Medicaid Services (CMS). The rule became effective Nov. 10, 2003.

The challenge, access professionals indicate, is in how to translate the EMTALA regulations into hospital policy, particularly as regards when financial information can be discussed with a patient.

"The big question is the stabilization vs. triage issue," says Monika Lenz, CAA, admitting/communications team leader at Ridgecrest (CA) Regional Hospital. "Now, after triage by a nurse, you can register the patient. We’re wondering about having to delay registration until after stabilization of the patient, whatever that means."

At present, she notes, access employees at her facility register emergency department (ED) patients after triage, at which time insurance information is verified. Now they are looking at delaying that step, to do a "quick registration" that gathers only the most basic patient information. The problem there, she says, is that entry into the computer system of just the patient’s name and date of birth triggers a screen containing information — including insurance data — from previous hospital visits.

In 1986, Congress enacted EMTALA to ensure public access to emergency services regardless of ability to pay, and it seems that hospitals have struggled with its interpretation ever since.

In conjunction with the effective date of the EMTALA final rule, the director of the CMS Survey and Certification Group issued a Nov. 7 memo to state survey agency directors "to clarify hospitals’ responsibilities when treating individuals with emergency medical conditions and to address concerns about EMTALA raised by the secretary’s Advisory Committee on Regulatory Reform."

The interim guidance, the memo explains, is to aid regional office and state survey agency personnel in enforcing the regulation until the release of Revised Interpretative Guidelines for EMTALA, which are being developed. It also may provide some help to access managers.

The memo, available at www.cms.hhs.gov/medicaid/survey-cert/letters.asp, states that CMS "would like to . . . clarify its policy regarding when a patient is stabilized and the hospital’s EMTALA obligation to inpatients." In a summary of the final rule provisions relating to EMTALA, the memo explains that "the rule codifies existing policy prohibiting a hospital from seeking authorization from an individual’s insurance company until a medical screening exam has been provided and any necessary stabilizing treatment has been initiated."

Although this policy is in the CMS State Operations Manual, and was the subject of a Joint Advisory Bulletin between CMS and the Office of the Inspector General in 1999, it never had been codified in the Code of Federal Regulations, the memo adds.

Also clarified in the final rule, the memo says, is "when an individual comes to the dedicated ED for nonemergency services, and from the nature of his or her request, it is clear that the individual is not making a request, or having a request made on his or her behalf, for examination or treatment for an emergency medical condition, the hospital is not obligated to conduct a comprehensive medical screening exam. Implicit in the guidance is the notion that it is permissible for a registered nurse to conduct the medical screening exam, as long as the nurse is considered to be qualified medical personnel [QMP] by the hospital and is acting within the scope of his/her license." In a provision intended to address hospitals’ uncertainty regarding stabilization, the memo states, the regulation defines "stabilized" as the point when "no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer of the individual from a facility."

The State Operations Manual further clarifies the regulation, the memo adds, by providing that the "treating physician or QMP attending to the person in the ED/hospital has determined, within reasonable clinical confidence, that the emergency medical condition has been resolved."