HCFA Task Force Tackles EMTALA Rules
HCFA Task Force Tackles EMTALA Rules
Attention ED managers: Are you concerned that your medical screening procedures may not measure up to federal guidelines? Do you know what kind of financial information you are allowed to discuss with patients whose visits are not authorized by their managed care gatekeeper? Do you know when you can appropriately transfer from a plan to a non-plan hospital?
If your answers to the above questions were yes, no, and no, you’re not alone, and HCFA has heard you.
The Health Care Financing Administration is beginning to consider recommendations made by its Anti-Dumping Work Group, a task force that was formed last summer to evaluate the administration’s policies and enforcement of the federal Emergency Medical Treatment and Active Labor Act.
"Hospitals and providers were telling us that some enforcement actions that HCFA had been taking put them on the hook for violations, when they were only responding to market pressures, largely driven by managed care, to get patients to the appropriate setting," says Jeffrey Kang, MD, Chief Medical Officer for HCFA’s Office of Managed Care.
The administration sought input from all of the "stakeholders" involved, recruiting physicians, hospital administrators, and representatives from managed health care plans, the insurance industry, and consumer groups. The task force is made up of representatives from such diverse organizations as the American Medical Association, ACEP, the American Association of Health Plans, the American Association of Retired Persons, Public Citizen Health Research Group, and the American Hospital Association, among others, says Kang.
"I like to think of it as negotiated role-making," he says. If all of the parties involved get together and form recommendations, then, when the changes are made, the transition will be that much easier, says Kang. "It’s this process that’s important."
"A lot of issues that we are trying to deal with through the Cardin bill on a legislative basis, we are talking about dealing with on this EMTALA task force on a regulatory basis," says Larry A. Bedard, MD, FACEP, President of the American College of Emergency Physicians and a task force member.
"We should be able to deal with a lot of these issues without going through legislation."
Bedard agreed that putting providers, payers, and consumers together was the right way to begin the process.
"This will be the first time we’ve [ACEP] had significant interaction with AAHP," he notes. "It’s been nice to sit down at the table and find out what their concerns are."
The main work group was divided into three subgroups, says Kang. The first group worked on clarifying the definition of terms the administration uses with respect to emergency services, he says.
"EMTALA requires treatment up to the point of stabilization, and they worked on establishing what stabilization was," he notes.
The second group examined enforcement issues, while the third group, the Interface with Managed Care Subgroup, looked at managed care’s payment for and coverage of emergency services.
• Definition of medical screening examination. One of the issues needing clarification was the definition of a medical screening exam. The task force draft of recommendations basically defines an MSE as a "process, not an event," states Bedard.
Evaluation in the ED changes based on the presenting complaint, and a proper screening examination would involve different levels of workup depending on the situation, he notes.
"I think [the recommendation] really clarifies it," Bedard says.
The recommendations also make clear that triage is not the same thing as a medical screening examination, he says.
• Definition of stabilization. Another issue is the definition of stabilization for the purposes of discharge or transfer to another facility.
"We all agreed that there should be no prior authorization until a patient is stabilized, and we all agreed on the definition of stabilization. [We further agreed] that stabilization for discharge home is different than stabilization for transfer to another hospital," he says.
• Signage in the ED. The task force also plans to come up with language for signs to be placed in EDs that would mention the patient’s financial responsibility for emergency services. One of the things that surprised him when he began work with the task force was that the HCFA representatives considered any sign mentioning financial responsibility to be coercion, Bedard says.
EDs across the country have signs indicating that the department will bill the patient’s insurance and the patient will be responsible for anything their insurance does not pay for, claims Bedard.
"Basically, half to two-thirds of hospitals in the country have signs that, if they got an EMTALA investigation, the agent could say they were violating the law." A subcommittee is trying to come up with language for a sign mentioning financial responsibility that would be acceptable to HCFA.
• Enforcement. Bedard says he also expects to see significant changes in the way COBRA/EMTALA provisions are enforced. Currently, he says, the penalty for any violation is a 23-day notice of termination from Medicare.
Under one of the group’s recommendations, if the violation did not have clinical implications, the termination track would be longer, he says.
"So, now, if you just forgot to send in the paperwork, they’ll probably change it from 23 days to 90 days," Bedard says.
The group would also like mandatory peer review of facilities if the violation involved an issue of clinical policy, he adds. "Right now, it’s permissive."
At the time of the interview with The Managed Care Emergency Department, the task force was scheduled to present its recommendations to HCFA at the end of February and the administration is expected to consider them, adapt them, and then send a version back to the members and their host organizations for input, according to Bedard.
Kang says the administration is considering some of the recommendations, but notes that there is not clear consensus among all of the parties involved on some of the issues.
"There are a couple of strategies [being considered]," says Kang. "One is to implement the changes that have been agreed onthe other is to wait until we have a consensus on everything to make any changes."
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