physician reviewer training: emtala
DESCRIPTION
Physician Reviewer Training: EMTALA. Sharon Hoffarth, MD, MPH, FACPM Chief Medical Officer. Objectives. Understand EMTALA from a regulatory perspective Understand the Physician Review Worksheet – the format, the regulatory definitions, the meaning behind the questions - PowerPoint PPT PresentationTRANSCRIPT
Publication MO-13-08-CRThis material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy
Physician Reviewer Training:EMTALA
Sharon Hoffarth, MD, MPH, FACPM
Chief Medical Officer
Objectives
• Understand EMTALA from a regulatory perspective
• Understand the Physician Review Worksheet – the format,
the regulatory definitions, the meaning behind the questions
• Understand the importance of a rationale that supports each
response
• Understand the links between questions to provide
consistency to the PR’s answers and rationales
• Understand Primaris’ internal process for conducting an
EMTALA review
• “Patient dumping”
− Sentinel cases in Kentucky and Missouri
• EMTALA
- Part of the Social Security Act
Revised §1866 and added §1867
- Known as COBRA 1985, effective 1987
- Applies to any and all individuals
- Regardless of insurance/Medicare status
Historical Perspective
Basic Tenets of EMTALA
• Applies to any facility with a designated ED & their physicians
• Facilities are obligated to provide medical screening exam (MSE)− Sufficient to reasonably indicate the presence or
absence of an emergency medical condition (EMC)
• If an EMC exists, then facility must:− Treat until stable or− Perform an appropriate transfer
• Patient-retained rights− Decline treatment− Refuse appropriate transfer− Request inappropriate transfer
Fundamental Requirements
• Medical screening examination (MSE) sufficient to determine
whether an Emergency Medical Condition (EMC) exists
• Necessary treatment provided to stabilize an emergency
medical conditions (including labor) prior to discharge or
transfer
• Determination of the necessity of transfer and a safe mode
of transfer, as appropriate
• The QIO must also identify any other concerns, particularly
quality of care issues
Medical Screening Examination (MSE) – Appropriate?
1a. Did the hospital provide a medical screening
examination that was appropriate to the individual’s
medical complaint(s) and symptoms?
- Triage is NOT an MSE; MSE is a process that may involve
multiple steps and reassessment over time
- Must be performed by a Physician or a Qualified Medical
Person (QMP) – for a psychiatric complaint, this may
mean evaluation by a psychiatrist or other qualified
mental health professional
Medical Screening Examination (MSE) – sufficient?
1b. Did the hospital provide (within its capability –
including ancillary services routinely available and
consultations by on-call specialist physicians) a
medical screening examination that was, within
reasonable clinical confidence, sufficient to determine
whether or not an EMERGENCY MEDICAL CONDITION
(as defined below) existed?
Medical Screening Exam -- Sufficient to Determine Whether an Emergency Medical Condition Exists
• Consider whether evaluation by or consultation with
psychiatrist or other mental health professional is indicated
• Must be sufficient to r/o out underlying:
- Trauma
- Disease/organic condition that might cause or contribute to
the presenting symptoms
• Substance Abuse
− Sufficient to r/o medical, toxic, psychiatric, and trauma causes
for the apparent state
Emergency Medical Condition (EMC)
2. Did this individual have an EMERGENCY MEDICAL
CONDITION as defined by Part (1) of the statutory
definition noted above? (Individual conditions
meeting the definition in Part 2 above are discussed
in subsequent questions.)
www.medlaw.com
Emergency Medical Condition -- Regulatory Definition
Acute symptoms of sufficient severity (including severe pain,
psychiatric disturbances, and/or symptoms of substance abuse) such
that absence of immediate medical attention could reasonably result
in:
• Placing pt’s health in serious jeopardy
• Serious impairment to bodily functions
• Serious dysfunction of any bodily organ/part
• This includes the health of a pregnant woman or fetus (Inadequate time to
effect a safe transfer before delivery and/or transfer may pose threat to health
of the woman or her unborn child)
• This also includes psychiatric conditions and substance abuse
Emergency Medical Condition – Psychiatric Conditions
• Medical conditions includes psychiatric conditions
− Severe depression
− Insomnia
− Suicide attempt or ideation
− Dissociative state
− Inability to comprehend danger
− Inability to care for one's self
www.medlaw.com
Emergency Medical Condition -- Pregnancy
3. Was this a pregnant woman who was having
contractions?
- If “Yes” and the pregnant woman was
transferred/discharged, at the time of the transfer/discharge,
could it be determined with reasonable medical certainty
that there would be adequate time to effect a safe transfer to
another hospital before delivery?
- If the pregnant woman with contractions was transferred/
discharged, at the time of transfer/discharge, could it be
determined, with reasonable medical certainty, that the
transfer/discharge would not pose a threat to the health or
safety of the individual or the unborn child?
Stabilizing Treatment
4. If an Emergency Medical Condition (EMC) existed, at the time
of transfer/discharge, was the individual’s EMC stabilized,
(meaning that no material deterioration of the condition was
likely, within reasonable medical probability, to result from or
occur during the transfer/discharge of the individual from the
hospital, or in the case of a pregnant woman in labor, that the
pregnant woman had delivered the child and the placenta)?
- Basically, can the individual be safely discharged home?
Stabilizing Treatment – Available Resources?
5a. Is there any evidence that the hospital was equipped with
such staff, services, or equipment necessary to “stabilize”
(assure within reasonable medical probability, that no
material deterioration of the condition is likely to result
from or occur during the transfer of the individual from a
hospital, or that a pregnant woman has delivered both the
child and the placenta) the emergency medical condition?
Stabilizing Treatment – available resources?
5b. If the hospital had the capability to stabilize the
individual and the individual was not stabilized prior
to transfer/discharge, is there any information
available to indicate WHY the emergency medical
condition was NOT stabilized prior to the
discharge/transfer?
Appropriate Transfers
Transfer is “movement (including the discharge)
of an individual outside a hospital’s facilities at
the direction of any person employed by (or
affiliated or associated, directly or indirectly,
with) the hospital, but does not include the
movement of an individual who….leaves the
facility without the permission of any such
person.”
Appropriate Transfer to Another Hospital
6a. If the individual was transferred to another hospital, is there evidence that
the sending hospital lacked the capabilities and facilities to provide further
medical examination and treatment to stabilize the individual’s medical
condition?
6b. If the individual was transferred to another hospital, did the transferring
hospital provide further examination and stabilizing treatment, within its
capabilities (including ancillary services routinely available to it) to
minimize the risks of transfers to the individual’s health and, where
relevant, the health of the unborn child?
Appropriate Transfer to Another Hospital -- Transportation
7. If the individual was transferred to another hospital, to
minimize the risks of transfer, did the transfer of the
individual require the use of qualified personnel and
transportation equipment, including life support measures if
medically appropriate?
8. If the individual was transferred to another hospital, were
the transportation equipment and personnel appropriate to
the transferred individual’s needs?
Medical Benefits of Transfer to Another Hospital
9a. At the time of the transfer, did a physician, or if a physician was
not physically present, another qualified medical person (in
consultation with a physician, who subsequently countersigned
the certification) certify in writing that, based upon the reasonable
risks and benefits to the individual, and based upon information
available at the time of transfer, the medical benefits reasonably
expected from medical treatment at another facility outweighed the
increased risks to the patient from effecting the transfer?
Medical Benefits of Transfer to Another Hospital
9b. Do you agree that at the time of transfer, based upon the reasonable
risks and benefits to the individual and based upon information available
at the time of transfer, the medical benefits reasonably expected from
medical treatment at another facility outweighed the increased risks to the
individual being transferred?
9c. If the individual (or a legally responsible person acting on the
individual’s behalf) requested the transfer in writing, was he/she informed
of the hospital’s obligations and of the medical risks of transfer?
Medical Benefits of Transfer to Another Hospital
10. Did the transferring hospital receive the agreement of the
receiving hospital to accept the transfer and to provide
appropriate medical treatment?
11. Does the documentation suggest that the transferring
hospital sent to the receiving hospital all available and
pertinent medical documentation related to the emergency
medical condition?
Medical Benefits of Transfer to Another Hospital
12. If the individual refused to consent to necessary
stabilizing medical treatment or to an appropriate
transfer, is there evidence the hospital first offered the
individual the further medical examination and
treatment or appropriate transfer, informing him/her of
the risks and benefits, and obtained the individual’s
informed, written refusal?
Recipient Hospital Refusal
13. Is there any evidence that a Medicare-participating
hospital that refused a transfer request has
specialized capabilities or services (not available at
the transferring hospital) that an individual required?
- Reverse dumping prohibited
- Hospitals with specialized capabilities may not
refuse appropriate transfer
- Patient requires such specialized capabilities
- Receiving hospital has capacity to treat patient
Delay in Treatment
14. Is there any evidence that the hospital under review
delayed for an inappropriate length of time the
provision of an appropriate medical screening
examination or further medical examination and
treatment?
Quality of Care
15. Do you have any specific concerns about the quality
of care rendered to the individual that have not already
been addressed fully above?
Summary
16. Please summarize the key facts of the case below and
any concerns or clarifications to your answers above
with regard to this case. Remember, do not state an
opinion regarding whether EMTALA was violated.
Initiation of an EMTALA Investigation
• Patient/family complaint
• Routine state survey
• Receiving hospital complaint
• Self disclosure
• Employee
EMTALA Investigation Prior to QIO Involvement
• Complaint acknowledgment (CMS)
• Investigate complaint (CMS & DHSS)
− DHSS state surveyors on-site
− Interviews
− Medical record & policy reviews
− ED log reviews
EMTALA Investigation – QIO Sequence
• Compliance determination (CMS)
− Immediate medical opinion (QIO)
− Advisory in nature only
• Statement of deficiencies (CMS)
• Plan of correction (from Hospital, and accepted by
CMS)
• Resurvey (DHSS)
EMTALA Investigation – After Determination of a Violation has been Finalized
• Due process provided to the hospital through the QIO
− 60-day review period
− Opportunity to discuss
− Case is re-reviewed and opinion forwarded to CMS
• CMS refers to OIG
− Consideration of exclusion and/or Civil Monetary
Penalties
EMTALA – Common Pitfalls to Avoid
• Specialist on-call says: “I can’t/won’t/don’t want to come in.”
• On-call physician says: “Call the surgeon/internist.”
• Patient’s Physician on the phone says: “Send her to my
office!”
• “There’s a Code in room 2.”
• “The doctor hasn’t answered my page.”
• Patient says: “I just want to get checked out.”
• Family says: “Can we take him in our car?”
EMTALA – Common Pitfalls to Avoid
• Insufficient systems in place
• Lapses in judgment
• Turf disputes
• Elopements
• Misunderstanding of “stabilized”
• Process not in place/followed
• Actively practicing
• Specialty
− Same specialty as attending physician or
− Type of service under review
• Practice in similar setting
• No conflicts of interest
• Agree to testify
QIO’s Internal EMTALA Review Process –Physician Reviewer Requirements
• Consider the information an ED treating physician:− Had, could have had, and/or should have had available to
him/her at the time of the individual's visit
− Is responsible to be aware of EMTALA provisions (e.g., §1867 provisions), and
− Could have discovered reasonably and which was necessary to adequately care for the individual (e.g., the physician should have taken an adequate history) at the time of the individual's visit.
QIO’s Internal EMTALA Review Process :Physician Reviewer -- Due Diligence
• Two levels of review
− 5 day review: the PR has 24 hours to review and return
the completed Worksheet
− 60 day review: the PR has at least a week to review and
return the Worksheet
− Primaris will overnight materials to the PR
− The Nurse Reviewer will make arrangements with you
to return the case file
QIO’s Internal EMTALA Review Process -- Summary
EMTALA References
• 42 CFR 489.24 and 42 CFR 489.20
− Special responsibilities of Medicare hospitals in
emergency cases
• 42 CFR 1003
− Civil monetary penalties & assessments
• State Operations Manual
− Interpretive Guidelines
• 42 USCA Section 1395dd
For questions and additional information, call Rita Ketterlin at 1-800-735-6776, ext. 153