ACA Timeline: Key Dates for Providers and Patients

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

There are requirements of EMTALA that are required to apply to ALL patients regardless of their ability to pay or insurance status

EMTALA regulations apply to all hospitals that participate in the federal Medicare program and apply to all patients (not just Medicare beneficiaries). Federal and military hospitals do not receive funds from Medicare and are thereby excluded from EMTALA; however, most abide by the regulations. EMATLA rules protect "any individual who comes to the Emergency Department" as well as those covered by the "250-yard rule." EMTALA defines an "Emergency Department" as follows:

  • Licensed by the state as an emergency department (this applies to states that license ED's separately from hospitals), or
  • Held out to the public as an emergency department or urgent care center, or
  • Have provided at least 1/3 of its visits on an urgent basis without requiring a previously scheduled appointment in the previous year

Once a patient is inside an ambulance, the ambulance may be diverted en route without violating EMTALA, since the patient has not physically "come to the Emergency Department." If the ambulance is owned by the hospital, yet is being utilized as part of the community EMS system, then those patients are not covered by EMTALA as long as the ambulance is being directed by EMS and not the hospital that owns it.

I worked emergency Departments before these anti-dumping laws and there are very good reasons why these laws had to be enacted and enforced.

Now here is where EMTALA can be "adjusted" and I have heard of some facilities out west that are "attempting" this interpretation differently.

In EMTALA patients are required to have a MSE (Medical Screening Exam) This is NOT a triage assessment by the nurse.

. It is important to understand that the MSE is not equivalent to a triage assessment. The definition of the MSE is "an evaluation reasonably calculated to identify emergency medical conditions suggested by presenting signs and symptoms." By definition, this evaluation may require the use of any diagnostic aids and/or specialty consultations normally available in the ED. For example, a patient presenting with chest pain, dyspnea, and diaphoresis may require an ECG, chest radiograph, and cardiac enzyme levels as part of the medical screening examination. The MSE must be performed by a qualified medical provider (QMP). Although the statute does not preclude a nurse or mid-level provider from performing the MSE, compliance generally is ensured if a physician evaluates the patient. In the case of a nurse or mid-level provider, the QMP must have a job description for this role, qualifications and competencies must be established, and a formal designation for approved individuals must be in their personnel file.

These facilities have developed their own sort of "urgent care" where a mid-level provider is involved to the triage process to determine IF a medical emergency condition exists......
Emergency medical condition is defined as the following:

"A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy, or serious impairment to any bodily functions or serious dysfunction of any bodily part or organ."

The physician and hospital do not violate EMTALA by failing to treat an unidentified emergency medical condition despite a good faith evaluation. For example, assuming an appropriate evaluation was provided, no EMTALA violation will be found if an emergency physician discharges a patient with an acute pulmonary embolism after erroneously concluding the patient's symptoms were attributable to costochondritis. Once a physician diagnoses the patient's condition, however, appropriate treatment must be provided if the patient's health is at risk.

Emergency medical conditions also include psychiatric emergencies (substance abuse, withdrawal syndromes). These patients must receive a medical screening examination calculated to identify underlying medical problems causing or contributing to their psychiatric condition.

Now just because a physician is not in violation of EMTALA for turning away a PE for muscle strain doesn't mean they can't be sued...however again this patient was NOT turned away at triage and sent on their way due to lack of payment/insurance and told.....
BlueDevil,DNP "this is not an emergency, go to minute clinic, urgent care or to your PCP." If the patient says they don't have a PCP and can't afford a visit, the answer is "that's a shame. save your money, go when you can."
and if they are it is the mid-level provider or MD that makes that determination and NOT the triage nurse.

Now EMTALA does not require a hospital to self report so you can't tell on yourself and get fined so if no one complains that you get off scott free....until you are caught and loose you medicare/medicaid CMS approval and stop receiving medicare payment. Which is highly unlikely a hospital will risk losing reimbursement especially when they are being reimbursed effectively

BlueDevil,DNP My company estimates we will get as many as 18,000 new primary care patients. Medicaid reimbursement is reasonable here, and they pay promptly 100% of the time, keeping collections up. We are going to need trucks to haul the tons of money we are going to rake in,
If you with to read more about EMTALA....COBRA Laws and EMTALA through medscape.....it requires registration but it is free and an excellent source of information.

So I do not see how the ACA affect emergency department visits unless it will be in the form of payment to the facilities that don't include the federal government because some of the uninsured will now have to pay hefty premiums to insurances companies who the pay the provider. I see the big money conglomerates just getting more money to line their pocket with little actual regard to whether or not people actually get sufficient care.

I live in a state that already has this as law and a very litigious state....it has done nothing to relieve the burdens of local emergency departments and lengthened the time it takes to see any PCP. I feel the quality of care has diminished when it is quantity that pays. You are allotted 10 mins for a visit. period...$40.00 co-pay and they bill your insurance co. $380.00 I have actually offered to pay for 2 office visits so I can feel like they hear ME and NOT the clock ticking saying time out. Concierge medicine is now in fashion....for a steep monthly fee....now that has improved healthcare for those who need it most.

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There are requirements of EMTALA that are required to apply to ALL patients regardless of their ability to pay or insurance status . . .

In EMTALA patients are required to have a MSE (Medical Screening Exam) This is NOT a triage assessment by the nurse.These facilities have developed their own sort of "urgent care" where a mid-level provider is involved to the triage process to determine IF a medical emergency condition exists......and if they are it is the mid-level provider or MD that makes that determination and NOT the triage nurse

I am aware of several facilities here in the Eastern US that have actually included an Urgent Care, Fast Track ER, Low Acuity ER, call it what they will into their existing hospital structure. Patients that do not require, as you point out, a more traditional ER setting are sent over to this other area. This has more than one benefit for the hospital. First, it prevents the hospital from being sued or charged with violation of EMTALA (like you I have not found any data to suggest that PPACA does away with EMTALA). Second, and perhaps most important to the hospital administration, it brings in money from patients that under a "tough luck go elsewhere" approach would take that money to other providers. Again it is important to assert that regardless of perception at least in my experience with ER patients just as many patients who have insurance show up at the ER for situations that may not require a "traditional" ER environment as do those without insurance.

Now I have heard several midlevel providers complain elsewhere on the internet that relegating them to "urgent care" takes away their skill sets. I do not intend to make this an argument or discussion on where midlevels should work nor even if the term midlevel is right or wrong. All that aside, however, midlevels like physicians have a choice of where to apply to work. If working "urgent care" cases versus "traditional ER" cases is not your thing then apply to work elsewhere (although in my experience midlevels, stationed in an urgent care or traditional ER, still see lower acuity patients unless they are the only provider available at the time a higher acuity patient comes in).

Another concern for the ERs that might employ the "we don't treat that here now get out" approach is the perception of discrimination. All it will take is someone to feel that they have been asked to leave based on some protected status (age, race, sex, ability to pay, national origin, religion, etc.) and a willingness to hire an attorney who can find that more people who fit their protected class we sent elsewhere than were those who do not fit into their class and well you have a perfect lawsuit. So, in short, ERs who employ this tactic must make sure that they are sending away equal numbers of whites as they are blacks, equal numbers of haves as they are have-nots, equal numbers of religious people as they are non-religious, etc. Otherwise they are setting themselves up for some nasty problems in the future.

Then again, high acuity patient or not I would not want myself or any of my loved ones being seen in an ER where someone was callous enough to give the "tough luck" approach to any patient to begin with (keeping in mind that there are plenty of chronic conditions that could warrant a visit to the ER: asthma, COPD, and HIV/AIDS just to name three).

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I live in a state that already has this as law and a very litigious state....it has done nothing to relieve the burdens of local emergency departments and lengthened the time it takes to see any PCP. I feel the quality of care has diminished when it is quantity that pays. You are allotted 10 mins for a visit. period...$40.00 co-pay and they bill your insurance co. $380.00 I have actually offered to pay for 2 office visits so I can feel like they hear ME and NOT the clock ticking saying time out. Concierge medicine is now in fashion....for a steep monthly fee....now that has improved healthcare for those who need it most.

This is the thing that a lot of otherwise well intentioned people seem to miss I think (and again I believe that many miss it completely in error). IF you have more people who want an item BUT you cannot charge more for the item (i.e. such as in traditional supply and demand theory) then you going to find a way to bring in that extra money somehow. One way to do so is in the way you just mentioned: see more people over less time. This does not increase the care the patient receives. It might not diminish the care either (depending on the provider), but it does not automatically increase the care the patient receives just because they now have insurance when they did not before. This is just another one of the "cause and effect" fallacies that is so very present in so many facets of society these days.

Another thing to consider is this: the patient who yesterday was not paying for insurance might have accepted care at a level they will not tolerate now that they are paying out $250+ a month to insurance. "Working me in" and making me wait for hours on end to be seen might be acceptable when I know you are going to make less from me, because I do not have insurance and you are cutting me a deal. However, once you are making the same off of me as you are the next guy well then I will get seen on time thank you very much. So, I think we might actually see an increase in lawsuits with more and more people having insurance.

As always just my two cents worth . . .

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

What I have heard ........is that there are some facilities out west that use mid-level employers to do a MSE as a part of the triage process indicating whether or not an emergent medical condition exists. AND....sending them on their way from triage...now how are they charging? I have no idea. How successful is it? I have no idea. Has it been challenged yet in a court of law....I am sure that is coming. But from what I have read/investigated....they are fulfilling the "MSE" part of the EMTALA requirements some of the practices I believe are going to put them in line with a lawsuit...or get their reimbursement for Medicare/medicaid pulled for it's a recipe for failure.....IMHO. The one I read about was a facility in New Mexico and one in Vegas I believe.

I have difficulty believing that ANY facility in this day and age would have the absence of mind to actually say "no pay no stay".....that just doesn't ring true for me...nor do I believe they turn away chronic conditions as has been indicated.....and if they are they need to be reported to CMS and other regulating agencies.

Having an Urgent care onsite as a part of the ED systrem is a HUGE benefit having a "Fast Track area" to send patients to get them in and out ....and it has raised over all satisfaction scores. It is still a traditional triage system with the triage nurse deciding which department to send them to...but we turn away no one. All are seen who wish to be seen ....even if it is for 5 min.

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What I have heard ........is that there are some facilities out west that use mid-level employers to do a MSE as a part of the triage process indicating whether or not an emergent medical condition exists. AND....sending them on their way from triage...now how are they charging? I have no idea. How successful is it? I have no idea. Has it been challenged yet in a court of law....I am sure that is coming. But from what I have read/investigated....they are fulfilling the "MSE" part of the EMTALA requirements some of the practices I believe are going to put them in line with a lawsuit...or get their reimbursement for Medicare/medicaid pulled for it's a recipe for failure.....IMHO. The one I read about was a facility in New Mexico and one in Vegas I believe.

I have difficulty believing that ANY facility in this day and age would have the absence of mind to actually say "no pay no stay".....that just doesn't ring true for me...nor do I believe they turn away chronic conditions as has been indicated.....and if they are they need to be reported to CMS and other regulating agencies.

Having an Urgent care onsite as a part of the ED systrem is a HUGE benefit having a "Fast Track area" to send patients to get them in and out ....and it has raised over all satisfaction scores. It is still a traditional triage system with the triage nurse deciding which department to send them to...but we turn away no one. All are seen who wish to be seen ....even if it is for 5 min.

I think the "Fast Track", "Urgent Care Area", "Low Acuity ER", etc. are all better alternatives to just kicking someone out the door.

What those who decide to "boot" need to realize is that if they go to court, and it is a jury trial, they will have jurors who will see this activity as "big medicine" trying to step on the little guy. Need an ER at that exact point in time or not.

Medicine is NOT an assembly line job, and the "you fit the mold or you're out" approach seems too much like QC on an assembly line to me. It is also true to say that while some ERs are busy hour to hour with "actual" emergencies, there are plenty that are not. Furthermore, I would assert that there are probably very few ERs that have more "real emergencies" every minute than they can handle (and if so they need to expand the ER).

Far from using PPACA as a way to get rid of ER patients, as I say, many ERs in the Southeastern part of the US where I am from are adding beds, low acuity areas, etc. to prepare for even more patients now that more people will have insurance (in my part of the country people are still prone to use "home rememdies" if they can't afford a doctor's visit -- ER or otherwise -- so these people will be moving from "Dr. Mom" to the ER to treat acute sickness once they have insurance).

And I agree with you concerning chronic conditions. I don't know how many decent ER Physicians would kick an asthmatic out the door (or to the local CVS or Walgreens) who feels they need to be seen active asthma attack or not (not, like I say, if they want to keep their medical license).

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I just thought of something else too. How do the "high acuity or the curb" ERs deal with patients who come to the ER at the request of their PCP? How about the patient that doesn't "present" like a "real patient"?

As anyone who has ever worked emergency medicine can attest a patient who says they just "don't feel right" but looks OK this minute may be in the resus room the next. So, if Patient A with a history of TIA calls his PCP and tells them he just doesn't feel right will he be "triaged out the door" if he doesn't say the right thing or present in the acceptable way at triage? Will he have the stroke sitting in a chair at the Walgreens waiting to see an NP after he has had time to tell everyone else who is waiting for the NP that his PCP told him to go immediately to XYZ ER but the people at XYZ ER told him "tough luck go to the Walgreens Clinic you aren't emergent enough for us"?

Perception is as much a part of maintaining a thriving medical facility as it is in any other business. So, as soon as public perception gets out that you "don't go there unless you want some rude person to tell you go somewhere else" then the policy will change or the facility will close. Either one would improve the quality of care it seems.

As always just telling it the way I see it . . .

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Specializes in Critical Care.

It's possible we're all talking about the same thing, more specific examples might be helpful. There really aren't big regional differences in how ER's manage and treat patients. For CMS participating facilities, EMTALA applies, although it could be argued that even for non CMS participating facilities failing to treat an emergent medical condition open themselves up to civil suit liability. If a MSE has been performed, and an emergent medical condition is not found, I'm not aware of any civil law precedent that requires they still be treated, beyond saying "you should see a doctor about that".

Non-emergent conditions aren't treated by ER's, this one reason why the biggest growth in healthcare once the ACA is fully implemented will likely be elective procedures, since hospitals currently have no obligation to provide medically necessarily, but non emergent or non-life threatening conditions.

And I agree with you concerning chronic conditions. I don't know how many decent ER Physicians would kick an asthmatic out the door (or to the local CVS or Walgreens) who feels they need to be seen active asthma attack or not (not, like I say, if they want to keep their medical license).

I think maybe we're confusing an emergent medical condition related to a chronic condition with a chronic condition. At least assessing and likely treating an active asthmatic exacerbation falls under both EMTALA and civil law precedents, overall management of their asthma doesn't fall under any ER obligations.

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Specializes in Critical care, tele, Medical-Surgical.

I know an ER nurse who told me that at her hospital a patient can be assessed by the triage RN and then taken to the urgent care accross the street if not in need of emergency care. A transporter walks or wheels the person for ingrown toenail, a cut thet needs suturing, or a young person with upper respiratory symptoms and no chronic illness.

It is better for true emergencies and also better for the person who probably not have to wait while the critically ill and injured are seen.

She said they tell others so more people go to urgent care rather than the ER.

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Non-emergent conditions aren't treated by ER's, this one reason why the biggest growth in healthcare once the ACA is fully implemented will likely be elective procedures, since hospitals currently have no obligation to provide medically necessarily, but non emergent or non-life threatening conditions.

I think maybe we're confusing an emergent medical condition related to a chronic condition with a chronic condition. At least assessing and likely treating an active asthmatic exacerbation falls under both EMTALA and civil law precedents, overall management of their asthma doesn't fall under any ER obligations.

First, I am sure that elective procedures will grow (they are already a good area of revenue for hospitals). Whether or not a hosptial is under an obligation to treat a specific condition does not mean that they will not. A hospital is a money making institution. If they can make money from treating a condition, obligatory or not, they most likely will. Also, I know of plenty of "non-emergent" conditions that are most certainly treated in ERs. Maybe some places kick out the "non-emergent" but not all. That is the whole point with low acuity areas of the ER, "urgent care" areas, etc. The patient who twisted his/her ankle, for example, is most often NOT an emergent case (as I am sure you are aware there are very few true orthopedic emergencies), but they will be seen and treated in every ER I have ever been associated with.

Second, I understand that overall management of asthma does not fall under ER regulations (although I am certain you can find patients who are, and have been, being "managed" in the ER and will continue to do so even after full implementation of PPACA). That said, legal precedent or not, it only takes one case of turning away an asthmatic who does not appear to be emergent who then becomes emergent and dies or suffers undue harm to result in the very legal precedent that may not currently exist. "Best judgement" as defined in the courts is not always the same as what may seem "best" for the ER at the time. That is why every ER that I have personally had any professional connection with at the bare minimum has a doctor see an asthmatic who is presenting. Even IF the asthmatic does not, in tirage, appear to be emergent. They might not be seen in 30 seconds, but they will be seen if they decide to wait.

One thing that I have sadly noticed is missing from this whole discussion, and some might say is missing from Emergency Medicine all to often on the whole, is the psychosocial issues effecting why a patient presents to the ER. IF the patient is presenting due to some mental disorder then, somatic emergent illness or not, kicking them to the curb will do nothing to help them nor will it keep them from showing up at your ER again. The patient who calls the ambulance just to have contact with another human being because their family does not come around needs social services not a "this isn't an emergency get the heck out" approach. The same goes for the patient who self presents at the ER.

There is very real danger in only doing what is obligatory. Sometimes what is right is better than what makes life the easiest.

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I know an ER nurse who told me that at her hospital a patient can be assessed by the triage RN and then taken to the urgent care accross the street if not in need of emergency care. A transporter walks or wheels the person for ingrown toenail, a cut thet needs suturing, or a young person with upper respiratory symptoms and no chronic illness.

It is better for true emergencies and also better for the person who probably not have to wait while the critically ill and injured are seen.

She said they tell others so more people go to urgent care rather than the ER.

See this is the kind of thing that to me makes a lot better sense than "sorry you aren't emergent enough for me so here's the door".

I think we can all agree that an ingrown toenail is not an emergent condition (even if the pain can be immense). With that said, the local walk in clinics, at least here, at places like CVS and Walgreens do not treat them as is the case with several PCP offices here. A podiatrist would be a good option, but there again there are none close by here. Also the county I live in does not currently have any stand alone Urgent Care Centers (the closest are 25 of 30 minutes farther than the closest ER). That is why the closest ER is, as I understand it, adding an "Urgent Care" area to their set up. It just makes sense. If people are going to stop there anyway then they might as well make money off of their illness/injury/issue.

No one is asserting that a lower acuity patient should trump a higher acuity one (and order you arrive of course should have nothing to do with it either), but to flat out tell a person "tough luck" reeks of all that the public perceives is wrong with medicine in this country. And that perception, like it or not, is what leads to the legislation and ultimately the cash flow, or lack thereof.

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Specializes in Critical Care.

I think we're all saying that ER's must assess for emergent conditions and treat them until the patient is stable enough for discharge or requires admission or observation for further assessment or treatment, nothing changes about that with the ACA and this general rule is followed throughout the country.

Issues not covered under EMTALA aren't dealt with any differently in any ER in any part of the country. For instance, a patient presenting with hip pain, found to be minor hip dysplasia still able to function independently at home, may benefit from a hip replacement, yet I know of no ER that will admit a patient from the ER for a hip replacement in this situation.

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I think we're all saying that ER's must assess for emergent conditions and treat them until the patient is stable enough for discharge or requires admission or observation for further assessment or treatment, nothing changes about that with the ACA and this general rule is followed throughout the country.

Issues not covered under EMTALA aren't dealt with any differently in any ER in any part of the country. For instance, a patient presenting with hip pain, found to be minor hip dysplasia still able to function independently at home, may benefit from a hip replacement, yet I know of no ER that will admit a patient from the ER for a hip replacement in this situation.

I can't really comment for other posters, but for my part yep that is what I was saying (even if I said it in a lot more words). Some other posters, however, made it appear that their place of employment was kicking people to the curb, and at least one poster said they actually gave people the "that's a shame" speech and told them to save up their money and go to a PCP when they could afford it.

Obviously patients are referred to a PCP, specialist, etc. every day in the ER before they are sent home. I guess what I am saying is there is a MAJOR difference between checking the acuity of the patient, providing treatment (even if not emergent life or death) if any can or needs to be provided at that time, and impressing upon the patient at time of discharge (be that three hours or three minutes after they came into their ER room/bed) the importance of having a PCP and/or the convenience, to them, both in time and money, of an Urgent Care or Walk In Clinic for lower acuity complaints compared to kicking someone to the curb in a rude manner. There is never, in my opinion, ever a reason that ANY health professional should be rude to a patient. In fact the rude "tough luck" approach is a lot less likely to ever change anything. Simply put it is a lot easier to sell an idea to someone if you treat them like a human being and tell them what's in it for them (less wait time, lower costs, etc. in the case of Urgent Care, Minute Clinic, etc.) versus coming across in a "we don't have time for you" manner regardless of whether or not you actually don't have time for them.

There is a right way and a wrong way to do these things I guess is what I am saying, and, like you, I do not see PPACA changing much of anything, if anything at all, about ER visits, the type of patients who visit, the wait times, nor the acuity level of those who show up.

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