Medicare Compliance & Reimbursement

Do you know when the Ophthalmology Department becomes part of the ED?

What are your compliance obligations under the Emergency Medical Treatment & Labor Act? Well, if you’re a Medicare-participating hospital that offers emergency services and someone shows up at your ED, you take care of them — whether they can pay for it or not.

But all things being fuzzy and complicated, what are your obligations under EMTALA, exactly? Hospital compliance expert Duane C. Abbey, PhD, dug into some of the details in a recent AudioEducator seminar (https://www.audioeducator.com/hospitals-and-health-systems/ed-coding-billing-and-emtala-compliance-06-28-2016.html).

What triggers EMTALA?

A man walks into an ED ... What happens next?

According to the Centers for Medicare & Medicaid (CMS), an EMTALA obligation is triggered “when an individual comes by him or herself, with another person, to a hospital’s dedicated emergency department and a request is made by the individual or on the individual’s behalf, or a prudent layperson observer would conclude from the individual’s appearance or behavior a need, for examination or treatment of medical condition.” (https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R60SOMA.pdf)

In this situation, the hospital is now obliged under EMTALA to provide an appropriate medical screening examination (MSE) for the individual, as well as a stabilizing treatment or an appropriate transfer.

What are grounds for EMTALA?

Now, if an individual who is not a hospital patient shows up somewhere else on hospital property (that is, the individual comes to the hospital but not to the dedicated emergency department), an EMTALA obligation may be triggered if, according to CMS, “either the individual requests examination or treatment for an emergency medical condition or if a prudent layperson observer would believe that the individual is suffering from an emergency medical condition (EMC).”

What is the 250-Yard Rule?

According to CMS, the term “hospital property” covers the entire main hospital campus, including the parking lot, sidewalk and driveway or hospital departments, and any buildings owned by the hospital that are within 250 yards of it.

Example: A patient with an emergency eye problem might bypass the hospital’s ED completely and go instead to the ophthalmology aree of the hospital campus, Abbey says. In this situation, under EMTALA, “ophthalmology” becomes part of the “emergency department,” he says.

What is the outpatient servicing exception?

However, if an individual is registered as an outpatient of the hospital and they turn up on hospital property but not to a dedicated emergency department, the hospital has no obligation under EMTALA to provide an MSE for that individual if they have begun to receive outpatient care. That patient is covered by the hospital conditions of participation (CoPs) that protect patient’s health and safety and to ensure that quality care is furnished to all patients in a Medicare-participating hospital.

So if such a patient experiences an EMC while receiving outpatient care, the hospital does not have an obligation to conduct an MSE for that patient, as such a patient is covered by Medicare CoPs and state law.

What if the individual does trigger an EMTALA obligation?

If you’re a Medicare-participating hospital that offers emergency services, you absolutely must provide an appropriate medical screening examination (MSE) to any individual who comes to the ED. And this MSE must be conducted by a qualified medical person.

What do you mean by qualified, exactly?

Does the MSE for a person at the ED have to be conducted by a physician?

Short answer: No. EMTALA allows an MSE to be conducted by any “qualified medical” person, such as an on-call physician, a nurse practitioner, or a physician assistant. But it’s up to the hospital to make the determination of who it considers qualified to conduct assessments.

Longer answer: While a range of medical professionals may be qualified to conduct assessments, an MSE by any person other than a physician has a much higher risk of being found insufficient under EMTALA, meaning that the hospital may not be able to bill for the service.

Why not? Hospitals are paid for those services that are “incident-to” those of the physician or qualified non-physician practitioner. This does not necessarily include nurses, at least per se. So while you may have met your EMTALA obligation when the nurse conducted the MSE, you probably won’t be allowed to bill for it because there was no service provided by a physician and the hospitals only paid for services that are incident-to those of a physician.

Workaround: If anyone but a physician performs MSEs in an Emergency Department, the hospital should require a phone consultation with the supervising physician, as well as sign off by the physician for transfers or services.

Next steps: After the MSE, you must take care of or stabilize the person, and either send them home or transfer them. Done and done — “that’s basically it for EMTALA,” Abbey says.

What if the patient refuses examination and/or treatment?

Under EMTALA, a hospital has met the requirement of a medical screening if it offers the patient the further medical examination and treatment required, informs the patient or another on his behalf “of the risks and benefits of the offered examination and treatment,” and the patient or another acting on his behalf refuses to consent to the examination and treatment.

Well, you tried. And that’s all that EMTALA asks of you.