AKA "the Patient Dumping statute", "COBRA"

EMTALA is an acronym for a federal law signed in 1986 by President Reagan that puts a variety of obligations on hospitals that have emergency departments, most notably to "screen" for and "stabilize" the "emergency medical condition"(s) of all individuals that reach the "campus" of the hospital without regard to whether the individual has insurance or other means of payment for these services. You've probably already guessed from the quotations that this is a pretty definition driven set of obligations.


Enforcement of this federal law is the responsibility of the Centers for Medicare and Medicaid Services (CMS), but usually begins with a visit from a state investigator acting on behalf of CMS. To try and achieve consistency among the investigators in all the states CMS publishes detailed guidance for them in its State Operations manual. So facilities subject to EMTALA (basically hospitals with emergency rooms) should be aware even before the investigator arrives what she or he will be asking to see.

In addition to fines and potential risk of losing the hospital's right to participate in Medicare, the statute also provides a private right of action - so individuals who believe that they have been harmed because of a failure to meet these obligations can sue for damages. Verdicts and settlements in excess of $3 Million have been reported in these cases although certainly not all result in any recovery for the patient / plaintiff.

Here's a look at the requirements of EMTALA compliance and enforcement through the eyes of an emergency room physician addressing his colleagues. And here's the same statute as presented by a CMS surveyor in 2013, including tips on "Avoiding a Violation".

Enforcement Highlights

2011 was a particularly notable - in the not so good way - year for EMTALA violations. The DHHS Office of the Inspector General's website contains the details of 10 settlements in 2011, including ones with Vanderbilt University and one of its on-call physicians who allegedly refused to accept a patient in need of specialized services, several with hospitals accused of failing to provide care to patients that made it to their facilities and one hospital that allegedly diverted a patient brought by EMS to two different EDs on its campus. Although the law was passed in 1986 - more than twenty-five years ago - apparently there are still covered organizations who are finding compliance with it difficult.

And the pattern continued in the 2012 Civil Monetary Penalty settlements. Three Boston area hospitals faced potential termination of their Medicare provider agreements because of EMTALA violations, according to reports obtained by the Boston Globe. Other reports also argue that EMTALA compliance was far from uniform even in 2012.

Also in 2012, Minnesota's Fairview Hospital came under scrutiny for the debt collection practices in its emergency room. Scrutiny from the state's Attorney General eventually led to separate federal investigation. The reports of that inquiry were recently made available and make interesting reading. First, they demonstrate that with EMTALA it's rarely just one of the obligations that results in a citation. The hospital was cited for the placement of its required signage and the maintenance of its "central log" - items completely unrelated to its alleged debt collection routines. Second, they show the ingenuity of a investigator determined to find a violation. The EMTALA regulation related to registration (482.24(d)) states that a hospital may not "delay" a medical screening examination or treatment in order to "inquire about the patient's method of payment or insurance status".(4). The reports detail several cases in which such inquiries (and more) occurred during the process of the patient's work-up, but none that show there was any "delay". So pulling out the rule books the investigators found additional duties in the hospital's conditions of participation relating to a patient's right to be free from "all forms of abuse and harassment" and cited the actions that arguably didn't violate EMTALA as violations of this provision.

2013 started inauspiciously with report of a settlement with a Florida Hospital that allegedly failed to screen and stabilize the condition of a pregnant woman and her unborn child who both subsequently died. The hospital paid $50,000.00 (the maximum liability for a single incident) to settle the Civil Monetary Penalty case brought by the DHHS OIG. An Illinois hospital also paid the maximum for failing to exam a 63 year old woman who was not breathing, but in April a Georgia hospital paid less for demanding $100 before continuing its examination.

Meanwhile, a tertiary care center paid $50,000 for refusing to accept transfer of a patient that allegedly required the Center's specialized capability. And three hospitals paid $20,000 each for failing to screen patients arriving at their emergency departments. In 2013 eleven settlements were reported by the OIG.

Getting The Message Out

Below is a presentation for training physicians and front line staff on EMTALA requirements. Maybe it will give you some ideas for communicating effectively about this topic in your organization.

EMTALA Resources on the Web:

Government Resources:

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