Emergency Med Quiz 1 - EMTALA and COBRA
How does EMTALA define an emergency?
"a condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the individual's health or the health of an unborn child in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of bodily organs." ***For example, a pregnant woman with an emergency condition must be treated until delivery is complete, unless a transfer under the statute is appropriate.
three main obligations of hospitals under the provisions of EMTALA
1. *Any individual who comes and requests must receive a medical screening examination to determine whether an emergency medical condition exists.* Examination and treatment cannot be delayed to inquire about methods of payment or insurance coverage. Emergency departments also must post signs that notify patients and visitors of their rights to a medical screening examination and treatment. 2. *If an emergency medical condition exists, treatment must be provided until the emergency medical condition is resolved or stabilized.* If the hospital does not have the capability to treat the emergency medical condition, an "appropriate" transfer of the patient to another hospital must be done in accordance with the EMTALA provisions. 3. *Hospitals with specialized capabilities are obligated to accept transfers from hospitals who lack the capability to treat unstable emergency medical conditions.* A hospital must report to CMS or the state survey agency any time it has reason to believe it may have received an individual who has been transferred in an unstable emergency medical condition from another hospital in violation of EMTALA.
Consolidated Omnibus Budget Reconciliation Act; when
1986
who by and when was EMTALA created
1986, Congress
What is EMTALA's scope?
> According to the law, EMTALA applies when an individual "comes to the emergency department." > CMS defines a dedicated emergency department as "a specially equipped and staffed area of the hospital used a significant portion of the time for initial evaluation and treatment of outpatients for emergency medical conditions." ***This means, for example, that hospital-based outpatient clinics not equipped to handle medical emergencies are not obligated under EMTALA and can simply refer patients to a nearby emergency department for care.*
what was the result of EMTALA?
> As a result, local and state governments began to abdicate responsibility for charity care, shifting this public responsibility to all hospitals. > Congress in 2000 made EMTALA enforcement a priority, with penalties more than $1.17 million in that year which was nearly as much as in the following 10 years, which was about $1.8 million. ***EMTALA became the de facto national health care policy for the uninsured*.
When does that coverage take effect?
> COBRA becomes available when an individual covered by a group health plan loses health insurance coverage because of a "qualifying event;" e.g., when an active employee's hours are reduced or job is terminated for reasons other than a person's gross misconduct. > Spouses and dependent children may become COBRA-eligible when a covered employee's job is terminated or hours are reduced; when the employee becomes eligible for Medicare; upon the employee's death; or in the event of divorce or legal separation from a covered employee.
How long does COBRA coverage last?
> COBRA begins on the date when a qualifying event triggers the loss of the health coverage. > The law allows up to *18 months of continued coverage for certain qualifying events and up to 36 months for other qualifying events or a second qualifying event during the initial period of coverage.* > Employers may choose to provide coverage for longer periods if they wish.
What are the requirements for transferring patients under EMTALA?
> EMTALA governs how patients are transferred from one hospital to another. Under the law, a patient is considered stable for transfer if the treating physician determines that no material deterioration will occur during the transfer between facilities. > EMTALA *does not apply to the transfer of stable patients*; however, if the patient is unstable, then the hospital may not transfer the patient unless: - A physician certifies the medical benefits expected from the transfer outweigh the risks OR - A patient makes a transfer request in writing after being informed of the hospital's obligations under EMTALA and the risks of transfer.
what are EMTALA requirements to hospital ED's?
> EMTALA requires Medicare-participating hospitals with emergency departments to *screen and treat the emergency medical conditions of patients in a non-discriminatory manner to anyone, regardless of their ability to pay, insurance status, national origin, race, creed or color*. > The Institute of Medicine in 2006 recommended that the Department of Health and Human Services adopt regulatory changes to EMTALA and the Health Insurance Portability and Accountability Act (HIPAA) so the original goals of the laws are preserved but integrated systems may further develop.
What's the process for COBRA?
> Employers and qualified beneficiaries must inform the health plan administrator that a qualifying event has occurred. > An employer has 30 days to give that notice in the event of an employee's death, termination, reduced hours of employment or entitlement to Medicare. > A qualified beneficiary has 60 days to give notice after a divorce or legal separation or when a child no longer is covered as a dependent. > A notice of the qualifying event must be sent to plan participants and beneficiaries within 14 days after the plan administrator receives notice that a qualifying event has occurred. > An individual has 60 days to decide whether to elect coverage. > After electing coverage, the person has 45 days to pay the premium.
Do employers have to offer COBRA?
> Generally speaking, group health plans maintained by private-sector employers with 20 or more workers are subject to COBRA rules. > However, if a company closed or went bankrupt and no longer offers a health plan, there is no required COBRA provision.
What does COBRA do?
> It allows certain employees, retirees, spouses, former spouses and dependent children to continue health insurance coverage at group rates for specifics time periods. > To be eligible, a person must have been enrolled in their employer's health plan when he or she was working for that particular company.
What are the advantages of taking COBRA?
> Qualified individuals are able to buy temporary health insurance coverage at the group health rate. > You will, however, pay more than active employees whose coverage is subsidized by the employer.
Emergency Medical Treatment & Labor Act (EMTALA) specifics
> Section 1867 of the Social Security Act imposes specific *obligations* on Medicare-participating hospitals that offer emergency services *to provide a medical screening examination (MSE) when a request is made for examination or treatment for an emergency medical condition (EMC), including active labor, regardless of an individual's ability to pay.* > Hospitals are then required to provide stabilizing treatment for patients with EMCs. > If a hospital is unable to stabilize a patient within its capability, or if the patient requests, an appropriate transfer should be implemented.
EMTALA payments cont.
> Some health insurance plans deny claims for legitimate emergency departments visits, based on a patient's final diagnosis, rather than the presenting symptoms (e.g., when chest pain turns out not to be a heart attack). > Some also attempt to require preauthorization before a patient can seek emergency medical care, resulting in denied payment. > These managed care practices endanger the health of patients and threaten to undermine the emergency care system by failing to financially support America's health care safety net. > American College of Emergency Physicians (ACEP) advocates for a national prudent layperson emergency care standard that provides coverage based on a patient's presenting symptoms, rather than the final diagnosis. > In addition, health insurers should cover EMTALA-related services up to the point an emergency medical condition can be ruled out or resolved
What are the penalties for violating EMTALA?
> Termination of the hospital or physician's Medicare provider agreement. > Hospital fines up to $50,000 per violation ($25,000 for a hospital with fewer than 100 beds). > Physician fines $50,000 per violation, including on-call physicians. > The hospital may be sued for personal injury in civil court under a "private cause of action" > A receiving facility, having suffered financial loss as a result of another hospital's violation of EMTALA, can bring suit to recover damages.
Who pays for EMTALA-related medical care?
> Ultimately we all do, although *EMTALA places the greatest responsibility on hospitals and emergency physicians to provide this health care safety net and shoulder the financial burden of providing EMTALA related medical care* > According to a May 2003 American Medical Association study, emergency physicians on average provide $138,300 of EMTALA-related charity care each year, and one-third of emergency physicians provide more than 30 hours of EMTALA-related care each week. > Physicians in other specialties provide, on average, about six hours a week of care mandated by EMTALA, and on average incurred about $25,000 of EMTALA-related bad debt in 2001.
How much do they pay for COBRA?
> You'll pay the entire premium amount, including the portion of the premium that your employer used to contribute toward your health benefits. > You may also be required to pay a 2 percent administrative fee.
what does EMTALA try to prevent?
> designed to prevent hospitals from transferring uninsured or Medicaid patients to public hospitals without, at a minimum, providing a medical screening examination to ensure they were stable for transfer
what qualifies and EMTALA violation?
An adverse patient outcome, an inadequate screening examination, or malpractice action do not necessarily indicate an EMTALA violation; however, a violation can be cited even without an adverse outcome. There is no violation if a patient refuses examination and/or treatment unless there is evidence of coercion.
What is the statute of limitations for violating EMTALA?
There is a 2-year statute of limitations for civil enforcement of any violation.
Consolidated Omnibus Budget Reconciliation Act; what
a 1986 federal law that allows for the temporary extension of group health coverage to people whose health benefits otherwise would be terminated. (i.e. if you lose your job)
EMTALA common name
anti-dumping law
Emergency Medical Treatment & Labor Act (EMTALA)
enacted to ensure public access to emergency services regardless of ability to pay
who penalizes for EMTALA?
Both Centers for Medicare and Medicaid Services (CMS) and the Office of the Inspector General (OIG) of Department of Health and Human Services (DHHS) have administrative enforcement powers with regard to EMTALA violations.
COBRA
Consolidated Omnibus Budget Reconciliation Act
EMTALA
Emergency Medical Treatment & Labor Act (EMTALA)
Provisions for the transfer of unstable patients
In addition, the transfer of unstable patients must be "appropriate" under the law, such that: 1. The transferring hospital must provide ongoing care within it capability until transfer to minimize transfer risks 2. Provide copies of medical records 3. Must confirm that the receiving facility has space and qualified personnel to treat the condition and has agreed to accept the transfer 4. The transfer must be made with qualified personnel and appropriate medical equipment.
