EMTALA outlines specific obligations for the referring hospital, the treating or transferring physician, and the receiving physician and hospital. The main points are as follows:
Medical screening exam
Any person requesting emergency services, who presents to a facility that provides emergency services, must receive a medical screening exam (MSE). The purpose of the MSE is to identify whether an emergency medical condition (EMC) exists.
This request can come from the patient, someone accompanying the patient, a law enforcement officer bringing someone to the ED, or someone walking into the ED requesting a blood pressure check.
If the MSE reveals an emergency medical condition, it is the obligation of the treating hospital to stabilize the patient prior to discharge or transfer.
Persons covered by the "250-yard rule"
In addition to persons who come to the ED requesting treatment, EMTALA rules also apply to any person who presents on the hospital campus and requests or requires emergency services. Known as the "250-yard rule," the hospital campus is defined below
- Campus means the physical area immediately adjacent to the provider's main buildings, other areas and structures that are not strictly contiguous to the main buildings but are located within 250 yards of the main buildings, and any other areas determined on an individual case basis by the HCFA regional office, to be part of the provider's campus" (42 CFR 413.65).
- The "250-yard rule" obligates hospital staff to recognize when a visitor, another employee, or anyone on the hospital campus, is in need of a medical screening examination. This includes, "Anyone whom a layperson would believe, based on the individual's appearance and behavior, that the individual needs examination or treatment."
- Campus typically includes the parking lot, sidewalks, driveways, and inpatient and outpatient areas.
- The campus does not include nonmedical businesses such as retail business, private physicians' offices, or other medical entities that have a separate Medicare identity.
The treating physician may transfer the patient in the following scenarios:
- The emergency medical condition has been stabilized and the patient requires a higher level of care.
- The emergency medical condition has not been stabilized, but the treating physician certifies that the benefit of transfer outweighs the risk.
- The patient or health care proxy requests transfer regardless of whether the emergency medical condition has been stabilized.
- The on-call physician fails or refuses to appear within a reasonable period of time, and without the services of the on-call physician, the benefit of transfer outweighs the risk.
When transferring, the treating physician must document the name of the accepting individual and facility. The treating physician must also send pertinent documents, imaging studies, and test results relating to the emergency condition to the receiving facility.
The receiving hospital must accept the transfer as long as they have the capacity and space to do so. It is the obligation of the receiving hospital or physician to report any transfer received in violation of EMTALA. The receiving hospital may be penalized for failure to report an EMTALA violation.
The transferring hospital must provide all medical treatment within its capacity, which minimizes the risk to the individual's health. Qualified personnel, with the appropriate medical equipment, must accompany the patient during transfer.
On-call physician duty
Hospitals must maintain an on-call list of physicians "in a manner that best meets the needs of the hospital's patients." Note that there is no requirement under EMTALA for full-time, on-call coverage by all specialties. However, the hospital is required to adopt a plan of action for situations where the needed on-call specialist is unavailable.
On-call physicians may be on call for multiple hospitals simultaneously and may schedule elective procedures during on-call hours.
On-call physicians are required to respond in a reasonable time period to assist in the stabilization of a patient with an emergency medical condition.
The ED physician's judgment should be deferred to by the specialist in situations where the ED physician requests the presence of the specialist, but the specialist does not believe that his presence is necessary.
Fulfillment of EMTALA obligations
EMTALA obligations are fulfilled when the following criteria are met:
- An appropriate MSE identifies no emergency medical condition.
- The patient refuses to consent to treatment offered or refuses to consent to transfer offered.
- The emergency medical condition is stabilized.
- A patient with an EMC is stabilized, admitted, and develops a new EMC.
- EMTALA obligations do not apply when an individual who is on the hospital campus for outpatient, nonemergency services develops an emergency medical condition after beginning the outpatient treatment (these situations are covered under CMS's "Conditions of Participation" rules).
EMTALA legislation is enforced by CMS. A hospital that has more than 100 beds may be fined up to $50,000 per violation, and a hospital with fewer than 100 beds may be fined up to $25,000 per violation. Individual physicians may be fined as well, including on-call physicians who fail to appear. On-call physicians who request that an unstable patient be transferred when the risk of transfer outweighs the benefit may also be fined. Ultimately, a hospital may have its Medicare provider agreement revoked in response to EMTALA violation.