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PED-EM-L  July 2004

PED-EM-L July 2004

Subject:

Re: FW: EMTALA question

From:

"Peter Glaeser, M.D." <[log in to unmask]>

Reply-To:

Peter Glaeser, M.D.

Date:

Thu, 8 Jul 2004 16:20:41 -0500

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (211 lines)

My reading of your lengthy response suggests that we are saying the same
thing, but have a different interpretation of the meaning, and since
there is no case law as of yet it remains to be seen how the regulations
are interpreted.

"A traditional appointment-based clinic remains outside the scope of
EMTALA."   Your statement....my point.

Many children's hospitals have "off campus" after hour clinics that help
off-load the ED (and provide lifestyle protection for private
physicians) seeing primarily lower acuity patients (urgent and not so
urgent care). They are not held out to the public as emergency centers,
nor licensed in the state as an ED, and can be referral only
(appointment-based). CMS acknowledges this which is why they set the 1/3
threshold for walk-ins.

Pete you-can-call-me-bold Glaeser



-----Original Message-----
From: Pediatric Emergency Medicine Discussion List
[mailto:[log in to unmask]] On Behalf Of McDonnell, William
Sent: Thursday, July 08, 2004 12:06 PM
To: [log in to unmask]
Subject: FW: EMTALA question

My comments were abbreviated for ease in reading, but were entirely
accurate.  An urgent care center affiliated with a hospital meets the
definition of a "dedicated emergency department" under the 2003 EMTALA
regulations if the facility is:
(1) licensed as an ED by the state; OR
(2) held out to the public as treating emergent or urgent conditions
without an appointment; OR
(3) provides at least one-third of its outpatient visits on an urgent or
emergent basis, without requiring an appointment.

Labor and delivery units, psychiatric units, and off-campus hospital
urgent care centers are specifically included within the description of
"dedicated emergency departments" in the new EMTALA regulations.  For
"dedicated emergency departments," the 2003 Regulations dictate that all
EMTALA requirements apply (including that an appropriate medical
screening exam must be provided to any patient who requests examination
or treatment for any medical condition.)

While it is possible that a few centers who call themselves "ED" or
"Urgent Care" might not meet any of the criteria for designation as a
"dedicated emergency department," I stand by my original position that
virtually all pediatric ED's and urgent care centers will be deemed
"dedicated emergency departments" under the regulations.  Being "held
out to the public as treating emergent or urgent conditions without an
appointment" is sufficient to qualify as a "dedicated emergency
department," and simply using the term "urgent care center" may very
well meet this condition.  Moreover, the regulations have specifically
included urgent care centers as "dedicated emergency departments."

A traditional appointment-based clinic remains outside the scope of
EMTALA.  But it is a very bold urgent care center physician or medical
director who refuses to comply with EMTALA.



-----Original Message-----
From: Peter Glaeser, M.D. [mailto:[log in to unmask]]
Sent: Thursday, July 08, 2004 9:51 AM
To: McDonnell, William; [log in to unmask]
Subject: RE: EMTALA question

"If your urgent care center is affiliated with a hospital and meets the
2003 EMTALA regulations' definition of a "dedicated emergency
department," (and virtually all pediatric ED's and hospital-affiliated
urgent care centers do meet this definition)"

This statement is not completely accurate. The urgent care clinic will
be considered a "dedicated ED" only if over 1/3 of the yearly visits are
for unscheduled emergencies.  If your clinic is referral/appointment
only and your walk-ins are less than 1/3 of total (CMS will look at the
year prior), then EMTALA does not apply.

It is interesting that the payor requires an ED copay; do they also then
compensate for visits as if an ED (include a facility charge in addition
to M.D. bill)?

Pete Glaeser

-----Original Message-----
From: Pediatric Emergency Medicine Discussion List
[mailto:[log in to unmask]] On Behalf Of McDonnell, William
Sent: Thursday, July 08, 2004 7:37 AM
To: [log in to unmask]
Subject: EMTALA question




        Dr. Zang:

        Your posting raises a number of important EMTALA issues.

        1.  It is crucial to recognize that your relationship
(contractual or otherwise) with any insurer or managed care provider is
absolutely irrelevant to your EMTALA obligations.  If your urgent care
center is affiliated with a hospital and meets the 2003 EMTALA
regulations' definition of a "dedicated emergency department," (and
virtually all pediatric ED's and hospital-affiliated urgent care centers
do meet this definition), then you assume the full complement of EMTALA
obligations to ALL patients, regardless of how the insurer characterizes
you.

        2.  It is absolutely unlawful under EMTALA to alter your
emergency evaluation and stabilization of a patient based on his
particular insurer or managed care provider.  Regardless of your
contractual terms with the insurer, you must provide the same medical
screening exam and any necessary stabilization that you would for any
other patient.  The EMTALA regulations are quite clear that refusing,
limiting, or even delaying emergency screening and stabilization in
order to obtain managed care provider approval, or in deference to the
insurer's disapproval, is impermissible.

        3.  An accurate disclosure of your costs and billing practices
is not inappropriate.  Moreover, EMTALA specifically permits hospitals
to collect demographic and financial information, so long as it does not
delay or interfere with emergency medical screening and stabilization.
However, it would be unlawful to make emergency screening and
stabilization of any patient conditional on an up-front co-pay.  The
delicate part here is that discussion of the co-pay, even if it will be
collected later, cannot be done in such a way as to give the impression
that evaluation and stabilization is conditional on some initial
payment.  Any information you provide on this issue must make it very
clear that you will evaluate and stabilize any emergency condition
immediately, and that payment and collection issues will be addressed
later.

        Those with an interest in this area or who have questions about
the new EMTALA regulations' effects on pediatric emergency practice may
wish to see the upcoming August 2004 Pediatric Emergency Care for an
article on the topic.

        William M. McDonnell, MD, JD
        The Childrens Hospital
        Denver, Colorado

                -----Original Message-----
                From: Pediatric Emergency Medicine Discussion List on
behalf of Peter Zang
                Sent: Wed 7/7/2004 7:05 PM
                To: [log in to unmask]
                Cc:
                Subject: EMTALA question



                I work at a free standing urgent care clinic.  One
insurance provider will not recognize us as an urgent care center (it is
in the contract with them) and their patients must pay an ER copay, even
though their plan lists an urgent care copay.  As you can imagine, some
families are not too happy when they realize this.
                My question is whether we can place a sign at the front
desk explaining the situation, or would that be construed as violating
EMTALA's restrictions on asking for financial information before a
patient is seen?  Is there a way of phrasing it to avoid any problems?
                Any suggestions would be helpful.  Fell free to reply to
my personal email - [log in to unmask]<mailto:[log in to unmask]>

                For more information, send mail to
[log in to unmask] with the message: info PED-EM-L
                The URL for the PED-EM-L Web Page is:

http://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html




DISCLAIMER:
CONFIDENTIALITY NOTICE:  The information contained in this message is
legally privileged and confidential information intended for the use of
the individual or entity named above. If the reader of this message is
not the intended recipient, or the employee or agent responsible to
deliver it to the intended recipient, you are hereby notified that any
release, dissemination, distribution, or copying of this communication
is strictly prohibited.  If you have received this communication in
error, please notify the author immediately by replying to this message
and delete the original message. Thank you.

For more information, send mail to [log in to unmask] with the
message: info PED-EM-L
The URL for the PED-EM-L Web Page is:
  http://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html



DISCLAIMER:
CONFIDENTIALITY NOTICE:  The information contained in this message is
legally privileged and confidential information intended for the use of
the individual or entity named above. If the reader of this message is
not the intended recipient, or the employee or agent responsible to
deliver it to the intended recipient, you are hereby notified that any
release, dissemination, distribution, or copying of this communication
is strictly prohibited.  If you have received this communication in
error, please notify the author immediately by replying to this message
and delete the original message. Thank you.

For more information, send mail to [log in to unmask] with the
message: info PED-EM-L
The URL for the PED-EM-L Web Page is:
  http://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html

For more information, send mail to [log in to unmask] with the message: info PED-EM-L
The URL for the PED-EM-L Web Page is:
  http://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html

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