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PED-EM-L  July 2004

PED-EM-L July 2004

Subject:

Re: FW: EMTALA question

From:

Abigail Williams <[log in to unmask]>

Reply-To:

Abigail Williams <[log in to unmask]>

Date:

Fri, 9 Jul 2004 17:55:55 -0400

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (330 lines)

If I were walking in to a free standing urgent care center with chest pain,
I would expect that someone would call an ambulance and attend to me as best
they could while awaiting an ambulance, not tell me that "if you cant pay
then you need to drive yourself to the nearest hospital....it happens not
infrequently ...  And it is for that reason that the courts have looked to
EMTALA - not to keep the patient there until you know what is wrong with him
but certainly to treat the unfolding emergency appropriately i.e.
transferring the patient to the hospital....if you want specific cases I
would be happy to provide them for you.  It makes sense in a way, either
treat the emergency or if you cannot then send the patient out....do not
leave them in jeopardy over money...


Abigail Williams, RN, JD, MPH
Abigail Williams & Associates, PC
370 Main Street
Worcester, MA 01608
Phone: (508)795-1955
Fax:(508)795-1710
[log in to unmask]


-----Original Message-----
From: Peter Glaeser, M.D. [mailto:[log in to unmask]]
Sent: Friday, July 09, 2004 2:15 PM
To: Abigail Williams; [log in to unmask]
Subject: RE: Re: FW: EMTALA question

"EMTALA is used however to define the standard of care for a free standing
center and I think that a compelling argument could be made in court that a
person with chest pain who is sent out the door because of an inability to
pay without being seen by a medical provider can hold the urgent care center
to the "standard of care" that is represented by EMTALA even if the statute
does not address non hospital based centers..."

When I read "EMTALA" and "standard of care" in the same sentence it makes
the hair on my neck stand up! EMTALA is about process, not standard of care.
I think that is probably what you mean, but maybe as an attorney on the list
you have knowledge of case law of which I am unaware.  Can you cite evidence
where EMTALA has been "used to define the standard of care for a free
standing center?"

A question for you and the group....if you were having chest pain, hx of
heart disease, shortness of breath etc., and walked into a free standing
urgent care center, would you want to be evaluated by the pediatrician
working there, wait for enzymes, ECG, etc., or have someone at the center
call 911 and give you an aspirin? (the latter approach could be construed as
an EMTALA violation depending on how it is orchestrated) Or how about a real
case recently at a hospital in our community: patient in the hospital jumps
out a window on the 6th story. The hospital is not a trauma center so they
call EMS who respond quickly and transport to the trauma center. Technically
this is an EMTALA violation, but it was the right thing to do for the
patient.

EMTALA has been expanded well beyond its original intent and has unintended
consequences (the road to hell is paved with good intentions).  Suggesting
it be expanded further to make things more "fair" exposes the real problem;
EMTALA is an unfunded mandate and band aid approach to a broken health care
system.

Pete Glaeser



-----Original Message-----
From: Pediatric Emergency Medicine Discussion List
[mailto:[log in to unmask]] On Behalf Of Abigail Williams
Sent: Friday, July 09, 2004 9:25 AM
To: [log in to unmask]
Subject: Re: FW: EMTALA question

The target of the legislature was hospitals when the original law was
passed.  The impetuous had at its root the court recognized public policy of
detrimental reliance in the now famous Manlove case.  That is to say that if
the patient sees a sign on the front of the hospital that states, in effect,
come here with your emergency and we will care for you and then the hospital
turns them away, they have relied on the representation of the hospital to
their detriment and possibly lost valuable time in seeking care.  At that
time, free standing urgent care centers were not prevalent and not
considered to have the same publicly recognized obligations to provide
emergency care as the hospitals.  It would seem fair that the for profit
free standing urgent care centers have the same obligation that the hospital
does when advertising for the same services...i.e. we are here to care for
your emergencies...but as of today, that has not been addressed by the
original law or any of the amendments..... Although it should be...EMTALA is
used however to define the standard of care for a free standing center and I
think that a compelling argument could be made in court that a person with
chest pain who is sent out the door because of an inability to pay without
being seen by a medical provider can hold the urgent care center to the
"standard of care" that is represented by EMTALA even if the statute does
not address non hospital based centers...


Abigail Williams, RN, JD, MPH
Abigail Williams & Associates, PC
370 Main Street
Worcester, MA 01608
Phone: (508)795-1955
Fax:(508)795-1710
[log in to unmask]


-----Original Message-----
From: Pediatric Emergency Medicine Discussion List
[mailto:[log in to unmask]] On Behalf Of Maggie Huey
Sent: Thursday, July 08, 2004 7:23 PM
To: [log in to unmask]
Subject: Re: FW: EMTALA question

Food for thought:  How do the non hospital affiliated urgent care center
chains  continue to fall outside the EMTALA  coverage?  They certainly meet
two of the three criteria listed below.  But it is my understanding that
there are no specific criteria that do govern  those facilities.

Maggie Huey, BSN, MHA
Director of Emergency Services
Cook Children's Med Ctr
Fort Worth, Tx

>>> "McDonnell, William" <[log in to unmask]> 07/08/04 12:06PM
>>> >>>
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
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prohibited.  If you have received this communication in error, please notify
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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

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Cook Children's Health Care System

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