EMS services, EMTALA, self-pay accounts

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I suppose i just want to vent more than anything and then listen to whatever responses I get. Just last night on shift we had a rollover MVA client we received to our ER. He was worked up and found to have had fractures on the first ribs and some spinal fractures in the thoracic area. He was stable. Our ER doc makes arrangement to transfer to a higher level of care to a level-one trauma center (that is also a charity hospital here in Lousiana). The local EMS was contacted for transport, and when dispatch found out that he was self pay and that this trip was going to be around $1600, they said that the client would be responsible for the bill and half the amount would have to be paid up front before leaving our facility. Administration at our hospital will only approve us picking up the tab for transfer if the patient request transfer (If they are self pay) but not if they are going for a higher level of care.:confused: So our hospital won't cover it and the EMS wants half up front (everyone has instant access to $800 right?) so we have a dilemma. EMS cant refuse transfer to higher level of care on the basis of ability to pay as far as I know and what our Nurse Manager over ER says. I shall do some more EMTALA studying today. What are some others input? Thank you for reading. Again this patient was not being transferred for charity reasons but rather for a higher level of care.

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Specializes in ER.

Ok, I'm still stuck on the hospital picking up the tab for a patient requested transfer, but not for higher levels (I guess you are too). That seems totally back-***-wards. The sending hospital has the liability when they determine that they can't care for the patient. But they certainly don't have any liability if Joe Bob thinks the food is better at Brand X hospital across town, and wants to check out the new Apple Brown Betty they're serving. Weird.

As for the EMS system, it's been a while for me on that end, but I'm pretty sure the ER nurse is correct, assuming that the EMS company has an exclusive contract with the hospital (or the city/county in general). Were they the same service that brought the patient to your facility in the first place? If so, the onus is on their backs for bringing the patient to the wrong facility in the first place. Even if they didn't bring them, they're basically refusing an emergency transfer (the patient isn't technically stable) and I can't imagine how they can justify that.

I'm interested in hearing others opinions and what you find out.

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Yes, they are the ones who brought them to our facility in the first place. They must bring them to the closest facility from scene as I understand it. And your right, the patient wasn't technically unstable, but was an "appropriate transfer" by EMTALA guidelines. The hospital we were transferring to is approx 70 miles from us so they could not have taken there anyway. I am still learning about EMTALA as I am now assuming a charge/leadership role alot of the time. As far as the administration goes, I don't understand it either. That is just what our house supervisor said the guidelines were? Hmmmm? Maybe I should speak with one of the administrators and defiinitely do some more EMTALA brushing up. This kind of stuff is not what you need in the middle of the night :banghead:. This has happened before but not to me. Seems like there should be some resolution at this point. No doubt, this is most likely a ubiquitous problem. Thanks for any input. cheers.:D

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Sorry. ...patient was'nt technically stable. My bad.

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Specializes in Emergency Department.

In all my years of ER and EMS experience, I have never heard of an ambulance service doing something like this--that is absolutely horrible. EMTALA is a bunch of legal mumbo-jumbo and difficult to understand, and it mainly applies to hospitals and hospital owned ambulance services--this was a private service correct? Did the service have a contract with the hospital to do patient transfers? These are all things you have to consider. While I am not sure that this consitutes an EMTALA violation, its pretty rotten anyway and is really, really bad customer service.

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Specializes in ER.

I just got off shift, so I'm gonna go sleep on this for a while. :wink2: I'm really interested in this scenario. I think a lot hinges on the contract the EMS service has with the hospital...and I can't imagine anyone signing an exclusive contract with a service that will only transfer "paying" patients. (What a sweet finacial deal the EMS got, if they did!)

Of course, maybe the ones who would sign that contract are the ones that will pay for a patient to transfer to a hospital with ESPN, but not one that is beyond their capabilities to care for! LOL!

Yeah, I'm gonna have weird administration dreams here in a little while. :D

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I do need to add that when I got off the phone with them, I spoke with a senior nurse who used to charge exclusively. She picked up the phone, called dispatch and requested to speak with a supervisor. The truck was soon dispatched and they transferred the client. OK, so first they MUST have half up front. Then they are dispatching a truck when someone superior calls them and they end up transferring with NO MONEY DOWN. Hmmmm? This is the honest truth. It just seems like stuff like this gets blown off where I work. Again, I am still learning and don't mind telling anyone that I have a lot to learn, but this is not right. Thanks again for the input.

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I don't know about your hospital, but at ours there are two ambulance services in town and they rotate. We have contracts with both to carry self pays or whatever needs to be hauled if going to the hospitals within a 60 mile radius from us. If it is a patient initiated transfer, I am not sure what the rules are.

If there is a problem in the future, you ask to speak to the dispatcher's supervisor and see what you get. If they realize you are not playing, then you won't have any problems.

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Specializes in ER/ICU/Flight.

it sounds a lot like the EMS didn't really want to do the transport in the first place. i've seen services try to "get out of doing their job" in many different ways.

was the ambulance service a county-based provider, private service or hospital-owned? the county-based EMS run by the local government has a responsibility to provide 911 coverage within the county lines and may refuse to transport to a referral center-at the risk of damaging their relationship with the hospital and EMS medical director. they could do this if it meant a lapse in the 911 coverage because a franchise contract is usually made to provide a 911 response within a certain amount of time (e.g. within 5 minutes of receiving a 911 call).

i've even been requested to fly a patient about 160 miles, when we got there we found the pt had an int, no o2, ambulatory and ready to go (can't remember all the details, i believe it was for an oncology consult later in the week). we did not end up flying her and after a little investigation we discovered that the person was self-pay and the local, private run ambulance service did not want to go on a 6-7 hour round trip that might end up being free.

emtala was basically enacted to prevent hospital "dumping" and that a person was guaranteed a right to be seen by a physician in the ER and would not be turned away if they were unstable. it is a lot of mumbo-jumbo and people yell "emtala violation" all the time, whether it's correct or not.

if i were you and entering a leadership role in the ER, i'd request a meeting with the EMS supervisor/director and your ER nurse manager to gain a better understanding of which model of service (public vs private), nature of any 911 contract, # of ambulances available during days vs. nights, etc. and also express your concerns over the recent situation.

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