Self Triage

chip193 · May 12, 2005

Per the EMTALA Gods, the triage nurse does not provide a medical screening. Yes, I know that patients are often waiting for hours in the waiting room (ours has become so bad that there is a "work room" where bloods can be drawn, EKGs done, and any other faster procedure done while trying to find a bed in the department!) but it still doesn't count.

Only a Medical Screening Exam by a physician or physician extender counts.

And you're not supposed to ask for insurance information until the patient has been screened. Most hospitals are in violation of EMTALA here - mine included.

Chip

future_nurse_Alex · May 12, 2005

I don't know where the myth comes from that one can't ask for insurance information prior to medical screening. My hospital has the same dumb rule but no one has ever shown me the part of the Act that states that. Here is what it does say:

http://www.aaem.org/emtala/1867.shtml

(h) NO DELAY IN EXAMINATION OR TREATMENT -- A participating hospital may not delay provision of an appropriate medical screening examination required under subsection (a) or further medical examination and treatment required under subsection (b) in order to inquire about the individual's method of payment or insurance status.

The way I read it, once the patient is triaged and waiting to be seen by a physician, you can get all their information as long as you're not delaying their screening.

Alex

PS: If anyone finds the paragraph that says no insurance info until after screening, please post it. Thank you.

chip193 · May 12, 2005

I don't know where the myth comes from that one can't ask for insurance information prior to medical screening. My hospital has the same dumb rule but no one has ever shown me the part of the Act that states that. Here is what it does say:
http://www.aaem.org/emtala/1867.shtml
(h) NO DELAY IN EXAMINATION OR TREATMENT -- A participating hospital may not delay provision of an appropriate medical screening examination required under subsection (a) or further medical examination and treatment required under subsection (b) in order to inquire about the individual's method of payment or insurance status.
The way I read it, once the patient is triaged and waiting to be seen by a physician, you can get all their information as long as you're not delaying their screening.
Alex
PS: If anyone finds the paragraph that says no insurance info until after screening, please post it. Thank you.

Alex,

Two problems:

(1) The screening exam must be done by a physician, PA, or NP.

(2) Case law has ruled that the screener (the physician, PA, or NP) should not

know what the patient has for insurance so that his opinion of the treatment needs will not be biased by the type of insurance.

Chip

future_nurse_Alex · May 12, 2005

(1) The screening exam must be done by a physician, PA, or NP.
(2) Case law has ruled that the screener (the physician, PA, or NP) should not
know what the patient has for insurance so that his opinion of the treatment needs will not be biased by the type of insurance.

1) Yes, the screening is done by an MD or PA but it may be an hour or so after the patient has been triaged, especially on a busy day. That gives me plenty of time to get all the registration paperwork finished before the doc ever goes in - no delay in screening.

2) Our docs and PAs don't know about the patients' insurance because it is handled by registration personnel and the information is not shared with them, it goes out to their billing service the next day.

chip193 · May 12, 2005

1) Yes, the screening is done by an MD or PA but it may be an hour or so after the patient has been triaged, especially on a busy day. That gives me plenty of time to get all the registration paperwork finished before the doc ever goes in - no delay in screening.
2) Our docs and PAs don't know about the patients' insurance because it is handled by registration personnel and the information is not shared with them, it goes out to their billing service the next day.

Ah...most places the insurance information goes right on the chart (or an ER face sheet, if you will). That's where the problem comes in.

Chip

mommatrauma, RN · May 12, 2005

Alex,
Two problems:
(1) The screening exam must be done by a physician, PA, or NP.
(2) Case law has ruled that the screener (the physician, PA, or NP) should not
know what the patient has for insurance so that his opinion of the treatment needs will not be biased by the type of insurance.
Chip

Chip, I see what you are saying but after reading the EMTALA laws and a few case studies...it seems its not that cut and dry...Its not so much what type of insurance its more of the managed care issues...Where managed care organizations used to require a pre-authorization for their patients but there was a law passed in 1997 prohibiting these such companies from requiring pre-auth for emergency visits...The other part of that is that as part of the registration process they are not allowed to ask for the co-pay or ask the patient to fill out financial forms unless they have already had their medical screening...because it may deter them from finishing their evaluation...It does not however say people can not be registered while waiting for their medical screening, nor that they can't give what insurance information they may or may not have...they just can't pay for any services prior to receiving them. Also, if it is a patient that has to pay a co-pay, they are not allowed to deny the patient a screening exam if they can't afford to pay their co-pay.

chip193 · May 13, 2005

Chip, I see what you are saying but after reading the EMTALA laws and a few case studies...it seems its not that cut and dry...Its not so much what type of insurance its more of the managed care issues...Where managed care organizations used to require a pre-authorization for their patients but there was a law passed in 1997 prohibiting these such companies from requiring pre-auth for emergency visits...The other part of that is that as part of the registration process they are not allowed to ask for the co-pay or ask the patient to fill out financial forms unless they have already had their medical screening...because it may deter them from finishing their evaluation...It does not however say people can not be registered while waiting for their medical screening, nor that they can't give what insurance information they may or may not have...they just can't pay for any services prior to receiving them. Also, if it is a patient that has to pay a co-pay, they are not allowed to deny the patient a screening exam if they can't afford to pay their co-pay.

The OIG from HHS has issued not less than two advisory opinions regarding the collection of insurance information before the medical screening exam. In both of the AOs that I have read, they state that the collection of insurance information and/or payment before the screening exam is completed violates EMTALA/COBRA.

EMTALA has nothing to do with the preauthorization that managed care required in the 90's. EMTALA was created in 1986 in answer to the problem of the uninsured being turned away from private hospitals and sent to public hospitals who would treat the uninsured. This led to deaths of patients and unborn children who were not stabilized (within the abilities of the facility) before transfer. This also led to the facilities that would treat the uninsured to be completely full and bursting at the seams and the other facilities would still send patients without report/accepting physician.

The following is the 262 page Federal Register new "final rule" on EMTALA. It is a very boring read! http://www.cms.hhs.gov/providers/emtala/cms-1063-f.pdf

Chip

mommatrauma, RN · May 13, 2005

The OIG from HHS has issued not less than two advisory opinions regarding the collection of insurance information before the medical screening exam. In both of the AOs that I have read, they state that the collection of insurance information and/or payment before the screening exam is completed violates EMTALA/COBRA.
EMTALA has nothing to do with the preauthorization that managed care required in the 90's. EMTALA was created in 1986 in answer to the problem of the uninsured being turned away from private hospitals and sent to public hospitals who would treat the uninsured. This led to deaths of patients and unborn children who were not stabilized (within the abilities of the facility) before transfer. This also led to the facilities that would treat the uninsured to be completely full and bursting at the seams and the other facilities would still send patients without report/accepting physician.
The following is the 262 page Federal Register new "final rule" on EMTALA. It is a very boring read! http://www.cms.hhs.gov/providers/emtala/cms-1063-f.pdf
Chip

Chip, thanks for the emtala lesson... :rolleyes: ...

13. Can the hospital inquire about the patient's ability to pay?

Yes, but timing is everything. The statute does not prohibit an inquiry into availability of medical insurance; it does provide that neither examination nor treatment may be delayed to make the inquiry.

Some knowledgeable commentators have suggested that no discussion of any payment issues should take place before the medical screening examination and any needed stabilizing treatment are provided. Others have found no reason for an outright prohibition on asking about insurance coverage while the patient is waiting for the examination so long as it is made clear that financial considerations will not affect decisions regarding examination and treatment. This is obviously an area with some dangers, and one benefit of absolute rules is that no one has to wonder where the line may be drawn. CMS has even recommended that hospital personnel not answer any questions initiated by the patient, apparently on the theory that some patients may be dissuaded from staying if they learn that they will be financially responsible for the treatment, even if they are assured that they will be seen without consideration of payment issues. Such recommendations, however, do not arise to the level of a definitive statement of what is required.

It should go without saying, but it unfortunately doesn't, that there should be no sign on the wall declaring any policy regaring prepayment of fees or payment of co-pays and deductibles.

A pre-authorization requirement imposed by a managed care organization or a health insurer may not be allowed to prevent or delay the performance of a medical screening evaluation or the instituion of necessary stabilizing treatment once it is determined that an emergency medical condition exists. There is nothing which prohibits concurrent contact with an MCO or an insurer, so long as that contact or the answer received is not permitted to interfere with the course of evaluation and (if there is an emergency medical condition) treatment. The requirements of EMTALA are mandatory and are unaffected by payment considerations. A hospital may not permit a denial of payment or uncertainty about payment to interfere with its obligations under EMTALA. The issue of payment or authorization for payment must not be allowed to influence the physician's decision as to (1) whether an emergency medical condition exists or (2) the nature or timing of the treatment needed. In February 1996, the Medical Services Administration changed its policies to provide for payment to providers for EMTALA-mandated medical screening examinations for patients receiving services through its MCOs. A prohibition against pre-authorization in Medicare and Medicaid managed care plans was then enacted into law by Congress in 1997 with the Balanced Budget Act.

In 1998, CMS issued a Special Advisory Bulletin -- reproduced at http://www.emtala.com/oblig.txt -- to underscore its position on this issue, in view of the fact that this is one of the most common sources of noncompliance. Its recommendations should be carefully reviewed. They offer some comments on common situations, including dual staffing arrangements, when calls to the MCO or carrier should be made, and how to respond when the patient inquires about payment issues.

emtala.com