[color=#000089]cms written standards for designation for a non-physician for mse and transfer decisions are items 1 and 2, while the remainder are those that have been articulated in various citations and should be considered "critical concerns" when a cms review is undertaken:
- the classification for qualified medical personnel other than a physician who is authorized to perform a medical screening exam in specified departments of the hospital has been approved by the board of the hospital directly or by board ratification of medical staff bylaws provisions. (the concept is that the board is privileging a non-physician to perform and extended role, much as a mid-level provider.)
- the scope of designation must be within the scope of practice for the designated provider under state laws
- job description for the role, qualifications, and competencies must be established
- formal designation for approved individuals is contained in their personnel records along with proof of specific emtala training appropriate to their role
- on-going documentation of competencies, qualifications, and quality review appears in the personnel records of designated individuals
- a written protocol exists defining the authorized functions of the non-physician
- the protocol must clearly define the point when a patient is considered beyond the non-physician's capabilities and a physician must complete the cme
- the rules must provide that the physician backing up the non-physician doing the mse is readily available and is mandated to promptly respond to provide the mse upon call or request.
discharge vitals and adequate discharge summary are necessary to support a discharge. un addressed complaints, unresolved abnormal findings, and undocumented or illegible discharge instructions are likely to be cited. full transfer documentation must support a transfer and justify the transfer under emtala.
criteria for non-physician (qualified medical person --qmp)
emergency medical conditions (emc's):
the term emc is much broader under emtala than under typical medical usage. this is a significant underlying cause for many emtala violations. the term includes any condition that is a danger to the health and safety of the patient or unborn fetus; or may result in a risk of impairment or dysfunction to the smallest bodily organ or part if not treated in the foreseeable future; and includes a specific range of itemized conditions:
- undiagnosed, acute pain sufficient to impair normal functioning is an emc [editorial comment: pain scale of 7 or greater is commonly associated with this level of impaired function, but this will be judged retrospectively by cms based on patient version and outcome, so documentation is critical. a lower pain value may not be "safe"];
- pregnancy with contractions present is an emc -- i.e. legally defined as unstable;
- symptoms of substance abuse -- i.e. alcohol ingestion;
- psychiatric disturbances -- i.e. severe depression, insomnia, suicide attempt or ideation, dis-associative state, inability to comprehend danger or to care for one's self.
federal law permits the obtaining of information in the routine registration qrocess, but the information may not be acted on -- i.e. no advance approval may be obtained from a third-party payer or employer.
calls to insurance companies or employers have repeated resulted in citations for emtala violation. handing a phone to the patient and having them call their insurance has likewise resulted in citations. cms specifically states that third-party payers do not have the authority to authorize treatment and that hospitals that follow hmo and insurance company procedures and directions will be cited for emtala violations.
patient transfers decisions may not be based on hmo/ppo direction or policy.
cms 2003 regulations strongly endorse the oig/cms prior "best practices" (translate that to "what we expect...") but do allow some slightly wider latitude. the basics of the "best practices" are: name and one other identifier at triage
- patients who are not triaged to the back my have routine registration that does not discourage the patient from completing care (comment: if you have a conditions of admission form with guarantors, personal liability statement, and assignment of benefits, you are at risk for financial discussions and resulting patient departures. cms has indicated that any system that induces departures will be at risk for citation for violating emtala.)
- you may ask for insurance information and copy the card
- you are strongly discouraged from any financial discussions at this point
- if the patient asks about financial issues, you are to say that finances can be dealt with following care
- if the patient continues to insist, the best practices indicate that a financial person experienced in emtala should hold that conversation (comment: i strongly recommend that physicians and nurses not discuss any financial issues with the patient at any time)
- you may contact a physician for medical purposes at any time, but not for gatekeeper permission to treat (comment: private physicians should be contacted only where there is a documented medical need, and no request by the pcp to send the patient to the office should be granted.)
- you may contact the insurance company after care is initiated (although most now do not require that), but if permission to treat or admit is denied, you still must provide the care. (so why call?)
- it is not required, but is considered a prudent approach, to separate the financial face sheet from the treatment record, so the treating physician is not aware of denials or types of insurance.
- once the patient has had an mse and is stabilized and/or admitted or the patient is determined not to have any emergency medical condition under the law, completion of registration and financial discussions may occur without emtala restrictions.
familiarize yourself with emtala/cobra before you accept any responsibility for this policy. it is a big deal!