ED Catch-22 means your hospital could lose big either way
ED Catch-22 means your hospital could lose big either way
Access managers urged to turn up the heat’ with legislators
Hospitals are being caught between a rock and a hard place in the way they handle emergency patients, and there’s no solution in sight. A direct conflict between the provisions of the federal Emergency Medical Treatment and Active Labor Act (EMTALA), also known as the "anti-dumping" law, and the screening requirements of HMOs leaves facilities and their access managers two choices: Obtain authorization from the patient’s primary care physician before treatment or provide a thorough medical screening before even mentioning the word "insurance" to that patient.
The second choice puts the hospital at risk of providing hundreds of dollars’ worth of free medical screenings for a patient, but the first carries a potential federal fine of $50,000 every time it occurs. Meanwhile, neither the federal Health Care Financing Administration (HCFA) nor managed care entities have presented hospitals with a way out of the dilemma.
As to whether HCFA might cut hospitals some slack because of this Catch-22, the answer is "absolutely not," says Bob Spain, Chicago-based program representative for HCFA’s Division of Health Standards & Quality. "From HCFA’s standpoint, the law is working," Spain says. In Illinois, for example, the number of cases in which women in labor have been "dumped" on county hospitals is way down, he notes.
The issue has been referred to the agency’s Office of Managed Care for review, Spain says. "We’re listening, and we’re trying to put a little common sense into the law," he told attendees at the recent National Association of Healthcare Access Management conference in Chicago.
Spain declined to speculate when the matter might be resolved, other than to predict only half-jokingly that it would be "by the millennium."
Meanwhile, the most important point for access managers and others who oversee emergency department (ED) procedures to remember is that they must not impede the patient’s progress to emergency treatment, he says.
The law gives a very specific definition of "triage" and "medical screening," and not until after a medical screening can the hospital get financial information, Spain emphasizes.
But there are steps you can take to help resolve the situation or at least keep yourself and your institution out of trouble, experts say. They include:
• Lobby lawmakers.
"What I suggest is to contact your legislators and apprise them of what’s going on that we’re following this rule at the risk of not getting paid," says Liz Kehrer, CHAM, patient access manager for Centegra Health System in McHenry, IL. "If we plant the bug in their ears and rally together, we can make them realize it’s something important and turn up the heat."
• Follow the law.
The potential $50,000 fine alone proves it’s a mistake to risk violating the anti-dumping statutes. Make sure your facility’s policies and procedures are in line with EMTALA, Kehrer says. Her health system established a task force to make sure it strictly adheres to the law.
If the patient involved is a woman or a member of a minority group, violations also can spark the involvement of the federal Office of Civil Rights, she notes. Kehrer has taken an aggressive stance in ensuring that both medical screening and proper discharge and transfer procedures are followed in her ED.
• Make sure medical care comes first.
Kehrer stresses that triage by a nurse is not enough to satisfy EMTALA requirements. "You can’t do triage and then turn the patient over to a registrar," Kehrer says. In fact, even if the patient offers his or her insurance card upon arrival in the ED, you shouldn’t take it. At her hospital, if patients complain because the insurance information isn’t taken when they first offer it, registrars are instructed to say, "Your medical care was more important to us." That practice actually has resulted in improved patient satisfaction, Kehrer notes.
At Centegra, the triage nurse obtains, on a separate form, the patient’s medical consent. That facilitates the ED process but has been "a difficult pill to swallow" for nurses, she says. "We just point out to them that they’re the ones whose actions are being protected [by the consent being obtained], not us." Procedures designed to ensure EMTALA compliance also put the onus for HMO authorizations on clinicians, Kehrer adds. They are done by nurses at the nursing station.
Centegra splits the ED registration process into two steps. First, during the demographic registration, the registrar asks only for the correct spelling of the patient’s name, the address, the date of birth and, if the patient has one, the family physician. A name plate and identification band containing this information along with the medical record number are issued.
Once the patient has been screened medi-cally, the registrar goes to the patient’s bedside in the ED and does the financial registration. Registrars are alerted that the medical screen is finished when the physician erases the patient’s ailment from a grease board that is used to track activity in the ED examination and treatment rooms.
The bedside ED registrations are being done manually, but Centegra plans to go on-line soon, Kehrer says. To streamline these registrations, she uses a "tag team" approach, with one registrar monitoring the door for incoming patients and another moving from bed to bed as needed.
• Document carefully.
One tricky area to pay close attention to is the way your hospital handles women in labor. Traditionally, when a woman in labor presents without contacting her physician, she is triaged by a nurse, who may call the woman’s physician and discuss her condition over the phone, Kehrer explains.
Make sure patients are examined
"If she’s not too advanced, [the physician] may say, I’ll come in in the morning.’ But the law now says the physician has to come in and examine that patient."
If not, the hospital could be penalized under the federal regulations, she says. That means you must document the call and the physician’s refusal. And if the patient’s own obstetrician won’t examine her, the hospital must get another physician to do the exam.
• Maintain an on-call log.
Hospitals are required to maintain a log of on-call physicians, so if a patient presents in the ED and needs, for example, an orthopedic surgeon, the physician is called to come in and treat the patient. If the physician refuses to come, that’s a violation of the law and should be documented, Kehrer says.
Obviously, physician compliance is a key part of EMTALA compliance, and it’s crucial that this be mandated from the top down, she adds. "You need support from the CEO."
Although EMTALA does carry fines for on-call physicians who refuse to come in and examine a patient, this portion of the law is widely misunderstood. Obstetricians at Kehrer’s hospital, for example, contend that the law doesn’t apply to them when the treatment of their own patients is in question. Spain recently clarified, however, that it does.
Such misunderstandings underscore the need for information regarding the law to be more widely disseminated, Kehrer says. During a recent site visit to learn about a nearby hospital’s computer system, she discovered that the ED was registering patients and gathering financial information from them immediately after triage. She alerted the person in charge, who had no idea the procedure violated the law.
"She panicked and immediately went to look for the hospital’s risk manager," Kehrer adds.
Take the EMTALA quiz
Kehrer has developed an EMTALA quiz to alert access managers to possible violations of the law by their facilities. (See copy of the quiz, p. 64.) It addresses, among other things, the need to establish who is allowed to perform medical screenings at your hospital, whether hospital policy jibes with state laws, and whether your facility’s EMTALA signs meet federal requirements.
It also addresses compliance with the part of the law that deals with transfer and discharge of patients from the ED. In the case of a transfer, for example, the sending facility should document the name of the physician or nurse who was notified that the patient was being transferred, Kehrer says. This protects the sending facility in the event that a patient arrives at a hospital that because of poor communication is not expecting the patient.
Centegra’s EMTALA task force also developed a two-page "Authorization for Discharge or Transfer to Another Acute Care Facility" form outlining requirements that must be met. (A copy of the form is inserted in this issue.)
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