The EMTALA law was created primarily to prevent hospitals and providers from denying life-saving/stabilising/emergent treatments from patients who could not pay. However, there are many intricacies of the law and how it is interpreted is widely debated. Hospitals and providers dread accusations of a so called “EMTALA violation” (which is a very expensive fine). Often these violations are unintentional. The reason is because EMTALA is widely interpreted to mean that if patients sense a “barrier” to care, they are being denied treatment. Such barriers are often unrealised by the hospital- no one is placing a sign that says the medical equivalent of “Pay first, Pump later” like you see at filing stations.
One debated action is the collection of co-pays. Some might argue that if patients know they will be charged their co-pay while in the ED, that they might decide not to get treated for their chest pain and then would drop dead from an MI. It is easier for a patient to just not worry about it and then when the bill comes several weeks later, they might just blow it off. Many hospitals have found that for patients who are discharged, having someone specifically assigned to the task approach the patient and ask them how they would like to pay their co-pay (obviously this is not done with self-pay patients) – they are then told that the ER will accept cash, cheque, or credit card. Many people wind up paying at least part of their co-pay right there on the spot – something they might not do if they were sent a bill. If the patient claims to have no money at all, they are not pressured but told a bill will be sent to them. Some hospitals have collected hundreds of thousands of dollars this way that otherwise would go unreceived. Some places are reluctant to do this however because of the perceived “barrier” to care and because they think it will be bad press for the hospital in the community (this I think is the case with my hospital). However, as far as I know, there have been no successful suits in cases like this – since they have already been treated and billed in discharge, not before the treatment began.
Another case was recently brought to my attention by a surgeon in my hospital. He was being accused of committing an EMTALA violation and was confused as to what he did wrong.
Apparently he was on call and came into the ED to evaluate a man who had cut himself in the hand with pieces of tile which were embedded in the skin. Tendons had been cut in the process. When he came in and told the a patient that he needed to take him to the OR, the patient said, “Wait, I am an independent contractor and have no insurance (he had also gotten rid of his workman’s comp), how am I going to pay for this”? The surgeon then said, “Don’t worry, we’ll just bill you”. “How much will that be?”, the guy asked. “About 10k-20k dollars.”, replied the surgeon. With that, the patient said he could not afford it and signed out against medical advice. He then went to a nearby hospital (which is a trauma centre) and presented with the same issues – they told him no details about being charged – in fact, they likely said something like “don’t worry, we’ll work it out.” The man was treated there but this other hospital accused our hospital of committing an EMTALA violation by setting up a barrier to care and thus forcing him to sign out and go elsewhere. Thus considered a “dump”.
The verdict has not yet been reached. However, it is my feeling that by telling the guy how much he will be charged before being treated (even if the surgeon did not realistically expect to get much money in the case) WAS perceived by the man as a barrier. Thus, it is probably technically a violation. If this had been an elective plastic surgery case (like a simple lac that the ER staff could easily perform), it would be different. But since it was a necessary urgency, one cannot discuss payment. I have often told people with no insurance who have needed emergent surgery for appendicitis or something similar that “don’t worry, it will be worked out”. If such people signed out and died because they felt they could not pay for their surgery, we could easily be sued. Not to mention the fact that to let someone sign out and die for such reasons would be unethical in my opinion.
Anyone else had similar cases?
To me, it seems that the patient was wishing to discuss something along the lines of a contract. Like, I want you to perform this for me, what is the price? It also seems unethical to withhold pricing information (when the price for the service can be reasonably estimated) when someone specifically asks for that. It’s like you’re entering into a contract to be paid while deliberately not telling the patient a rough estimate of what it will cost.
Just as some nurse, I would think it wouldn’t be an EMTALA violation if the patient asks you for the information and you don’t deliberately lie about the price to get him to go elsewhere (like if the surgery was $10,000 but he told him $50,000). When you’re self-pay, price IS a factor. There would have been no way for the surgeon to know that the patient had some arbitrary upper limit on price and he would go elsewhere if the quoted price was more than that.
Right, hence I think the safest thing is that if a patient needs something done that visit (ie something that cannot wait)to never discuss cost/price/money at all.
I agree with TK but a tendon repair is NOT an emergency and is frequently deferred for several days. I think the surgeon was perfectly within his rights to state the price of his procedure and the patient had every right to make a prudent financial/medical decision to seek cheaper care elsewhere. Where does hospital #2 get off making a lawsuit out of that?!
It amazes me that it could, even theoretically, be illegal to inform someone of the cost of a procedure before it’s performed. Stunts like this, which are clearly not the fault of doctors themselves, are exactly why people mistrust and dislike the whole health care system. Imagine if your car broke down and you called a AAA type service, who then said ‘We can help, but we aren’t allowed to tell you how much it will cost until you already owe us the money.’
I think I’d walk home.
Whitecap RN, I agree that tendon repair can be deferred but the foreign bodies were large and needed to be removed . The wound was highly infection-prone and needed a good cleaning in the OR as well.
I don’t think that stating the price of a procedure when the patient asked outright is an EMTALA violation. Perhaps the answer could have been framed differently, such as “the procedure is 10K but there are ways to work it out”, but I definitely don’t think that answering a patient’s question honestly is a violation of any kind. He asked a question, and then made an informed decision based on the answer he got.
I had to take a moment to think this over critically, because at first this struck me as absolutely ludicrous. It was a situation where honestly and properly informing a patient of a truthful piece of information was being construed as an infraction of some sort. The whole concept of EMTALA itself is flawed. As a society, I believe we should have a safety net for people with need for life-saving medical care. However, why does that burden fall solely on the shoulders of the ER’s and hospitals? This is a violation of the principles of freedom that our country is supposedly founded on. The government is essentially saying “We are forcing you to do this act of charity. But we will not help you financially.” All of a sudden, it no longer becomes an act of charity. I contribute a great portion of my time and resources to volunteering, both medically and non-medically, but if somebody forces me to do it, it turns it from a pure act of altruism to something ugly and coerced.
Ridiculous on an ethical level. If the truth is a violation, then the law is unethical, not the information. Not that this would in any way distinguish from the zillion other laws on the books.
Regardless of what we think is the right thing to do, an EMTALA violation has occurred if the Medical Screening Exam was delayed for the collection of financial information or The patient was coerced to leave prior to the completion of the MSE. Coerction to leave can occur with any discussion of costs or request for co-pays so these discussions should not occur until discharge. The MSE is not complete until a Emergency Medical Condition is “Stabalized” which can include the entire visit up to and including surgery if necessary. If you want to read about every day EMTALA violations go to the HHS webside – They name names and circumstances of setteled EMTALA violatins. Available at the link here http://www.oig.hhs.gov/fraud/enforcement/administrative/cmp/cmpitemspd.html
Dont like it – Change the law.
“financial coercion” and EMTALA see “…Patient Inquiries…” and “Voluntary Withdrawal” in PDF (Federal Registry 1999): http://snurl.com/26u3b
Gee, I’m glad I live in Australia with its ‘evil’ socialised medicine, where the government (and taxpayers) cover emergent care issues.
I had never heard of this law until my son got a one inch laceration on his forehead and the plastic surgeon refused to come in to suture him. Instead, he received four stitches from the nurse practitioner running the ER. The stitches look terrible, the scar looks terrible. I know that time will tell but had a plastic surgeon been the one to give him delicate well sewn stitches, I’d feel that my son got the best care possible. I have read and reread the statute and it seems that the hospital and the plastic surgeon are in violation of this law. What are your thoughts?
Ana Maria, technically the hospital and the surgeon did not violate EMTALA. It sounds like your son had a wound that did not REQUIRE the skills of a plastic surgeon. To have him or her come in would only have been for cosmetic reasons (which is not a emergency – and EMTALA only states that stabilising care be provided). Had the wound transected the eyelid margin or the parotid gland, then it is a different story – for the most part only plastics people do those repairs. Although you are not satisfied with the suturing job of the practitioner, it is because she did not do a good cosmetic closure – she did do what EMTALA requires. Simple lacerations like this are closed by ER staff all the time and usually they do a good job. The problems arise when someone with no insurance demands to have a plastic surgeon come in and repair a simple lac. Since it is a simple lac and is under the category of repairs that ER people are trained to do, the person would have to pay cash for the surgeon to come in- and he or she has the right to demand that they pay since it is entirely elective on a cosmetic basis. Do you have insurance? If so, I am surprised the surgeon would not come in and do the repair since most insurances would pay them fairly well. But no EMTALA violation occurred in your case.
Hi- thanks for your response. I do have an insurance. It is pretty good insurance at that. I would have gladly paid for his services since he my son is so little. Unfortunately, this is round two of stitches for him. The first time, we took him to a suburban northern NJ hospital and I didn’t even request the plastic surgeon-the ER doctor suggested it because it was on his face (albeit under his chin). We happened to be far from home this time and the nearest hospital caters to a mostly inner city population. I’d like to think that the plastic surgeon didn’t assume he had a kid from the guetto with no insurance and therefore not coming in but I can’t understand the discrepancy in treatment between the two ER’s. What a jerk. What a disservice to the local population of that hospital.
I came accross a comment by emtala exper Steve Frew’s who says:
Regarding cosmetic closures when patients come to the ED: if the emergency physician requests that the plastic surgeon come and see the patient, even if the initial patient request was only for cosmetic reasons, the consult falls under EMTALA just like any other consult, and failure to respond, if cited, will result in a fine.
http://www.pitt.edu/~kconover/ftp/emtala-draft.pdf (pg 33)
Not really sure where he gets to that conclusion.
As far as I know that is not the case. Otherwise all “elective” things would fall under EMTALA, and believe me we have to call tons of private MD’s (not just plastic surgeons) to come in for patient requests even though it is not medically necessary at the time. I always tell a plastic surgeon that the patient has insurance when they want them to come in for a purely cosmetic closure – I emphasise that the wound is simple and I could close it but the patient is requesting it – that way it does not look like I am dumping cases onto them – however, most of the time, the surgeon is glad to come in (it may take them a while since they cover numerous hospitals at once) for a simple case if they know they are going to get reimbursed for their services. Now, if I get a drunken homeless guy who fell and cut his parotid duct – the surgeon HAS to come in and his refusal to do so WOULD be a violation since this is NOT cosmetic or elective at all.
[...] EMTALA-orama: don’t discuss payment in the emergency room if you don’t want to get sued. [ER Stories] [...]
I’ve been reading along for a while now. I just wanted to drop you a comment to say keep up the good work.
(coming to the party really late because I’m reading my way back to the beginning.)
I’ve been that patient. Whenever I’ve been able to have insurance, I’ve had it and had the maximum premium for benefits. In 2003, while I had insurance, I was in Canada on vacation and I went to the ER for sudden excruciating 10/10 abdominal pain with vomiting and fever. I was 28 years old, nonsmoker, never touch alcohol or any other kind of drugs, vegetarian. Literally passing out from the pain every time it hit. I was asked to fill out a bunch of paperwork. They weren’t sure my American insurance would cover it and I was firmly informed many, many times that I would be expected to pay the bill if my insurance didn’t. (It did.) I had to sign or they wouldn’t see me. I was given a series of X-rays, and when I asked why they were giving me XRs for /abdominal pain/, I was told it was “standard”. During the blood draws, the phleb popped the veins in my arms two or three times on each arm, to the point where they had to butterfly it into the wrist and I was left with bruising and swelling so bad I couldn’t bend either elbow without pain. I was given Morphine – which I am allergic to and was listed on my chart and red-banded on my arm. I had to get epi, because I went into anaphalactic shock. I was given “an anti-nausea”, which they never identified, and then told “there was nothing on the films. It’s just heartburn. Go home.” It was crappy care, I felt they’d invalidated my concerns about my condition, and I felt like they’d deliberately given me the lowest standard of care because they thought my insurance wouldn’t pay, or that I wouldn’t pay. I was sent home, still vomiting and in horrid pain, believing it was “just heartburn”. By the time I returned to the US, it had resolved. I made the mistake of not following up with my PCP. Because it was ‘just heartburn’. I bought Prilosec, but that didn’t help.
A month later, the company I worked for went under and I didn’t get COBRA – couldn’t afford it at $650/mo. I kept waking up in the middle of the night with horrid burning chest pain that felt like someone had tied a rubber band made of acid around my middle, right under my sternum. I have a high pain tolerance but this was awful enough that I was willingly taking Vicodin leftovers from sinus surgery. Because it was “just heartburn” and I had been told that if I went to the hospital, I would be required to pay for care and I couldn’t afford it. During this time, I also had what I thought was an allergic reaction to something – my hands kept itching. The palms and fingers would itch so bad I’d scratch them bloody and Allegra and Benadryl topical didn’t help at all. This went on for three months until one night, the chest pain was so bad I had to force myself to breathe in and out – why is it that people hold their breath when things hurt? – and I was sweating so badly that I wound up sitting in a puddle. It wasn’t lower left quadrant, it was upper right quadrant and right under my sternum, which I kept chanting to myself in my head – “Not appendix.” I felt something go *pop* and it hurt REALLY BAD, and then the pain went away. I went to sleep. When I woke up, I felt sore and like I’d been punched, but otherwise totally fine. I had a bowl of Golden Grahams… and two minutes later, doubled over in pain, vomiting my guts up. I called the ER and they insisted I come in. I said I didn’t have insurance, I couldn’t afford a bill, and the nurse (bless her) calmly said, “It’ll be ok. Come in. We’ll take care of you.” So a friend drove me to the hospital. Triage nurse asked what my pain level was and again, 10/10 – and oh hey look, about to vomit with pain. She handed me an emesis pan, I shook my head and she handed me a bucket and up came the remaining cereal and a whole lot of bile. And then I passed out. When I woke up, I was in a bed, hooked up to an IV, saline bolus. It took over an hour for a doctor to get to me (car crash came in – not a complaint on my part), but when he did, he poked my side and said, “Does this..” and I passed out again. When I came to, he said, “It’s your gallbladder. You’re going in for an ultrasound as soon as we get a free tech.” I was given potassium, antibiotics, and painkillers. I started crying because I couldn’t afford an ultrasound, or surgery, or any of that. Nurse chimed in with, “Don’t worry. We’ve got a social worker here and she’s going to take care of that. Minnesota has a program for people who need care. It’s like temporary insurance – it’ll cover you. It’ll be ok.” I was given Demerol and they did an ultrasound. The doctor came in and began talking urgently to the tech about someone named Billy Rubin, whose stats were high, 3.5 when they should be .3, and it was really bad. I asked if he was supposed to be talking about someone else’s stats in front of me and he said, “Sweetie, that’s you. It’s the amount of bile in your blood. I don’t know why you aren’t as yellow as a banana right now.” Which was really funny, due to the narcs. No jaundice at all, through any of this. There was a 2cm stone blocking my duodenum. The “pop” I’d felt had probably been when it had been forced out of the gallbladder sphincter, and it had promptly gotten stuck somewhere else. The duodenum was swollen and putting pressure on the vein or blood vessel underneath, which was also swollen twice its normal size. My organs were starting to fail from the amount of bile in my blood and from the swelling squashing my pancreas and liver. I needed surgery RIGHT THEN to get the stone out – I was a time bomb. They were hoping to push antibiotics for 24 hours but didn’t want to wait that long for surgery. I got booked with the first available surgeon, who was at a hospital an hour away. Off I went for an ERCP. The ERCP surgeon walked in, looked at the chart, and exploded, “Why the hell didn’t they schedule her for a (gallbladder)ectomy? Honey, we’re scheduling you for surgery for tomorrow morning, because there are more stones in your gallbladder and if we don’t take it out, I can go in and get this one and you could be right back here an hour later with another one.” They went in, they got the stone out. I woke up with no more pain. Six hours later, I went in for lapro surgery to have the gallbladder removed. I asked them to save any big stones. When I woke up, I had a jar of four, all of them over a cm in diameter. Those were “just the big ones”.
At the time, I didn’t know how bad off I was. I knew it hurt. I knew it had to be bad because I’d been fast tracked for an ultrasound and shunted for emergency surgery. I came very close to dying or winding up with permanent organ damage. I got very lucky. I got a nurse on the phone who told me “It’ll be ok. Come in. We’ll help you.” When I was freaking out and asking how much all of this would cost, I had people who didn’t tell me – all they said was, “Don’t worry about it. We will take care of you.” I almost didn’t go in, because the last time I’d gone in, all I’d heard was “YOU MUST PAY!!” and I put off care a lot longer than I should have.
Our governor has basically done away with MinnesotaCare – the program that footed my very large emergency bill. I saw it later, after it had been paid. I think my portion came to $186.00. I am glad nobody told me the big numbers, or even mentioned just how big those numbers would be, while I was in crisis. I was already in pain and panicking, and in no condition to be making rational decisions. I very likely would have signed out AMA if someone had mentioned them around me – even if they’d told me I wouldn’t have to pay it, I’d have felt bad being a drain on the system – I was in NO CONDITION to be making that decision, and I’d have died.
When I (much later, after I’d recovered) requested my medical file, I got a surprise. My surgeon had looked up the hospital in Canada that had sent me home with ‘just heartburn’ and a fear of going to the hospital. He’d written them a three page letter ripping them up one side and down the other.
So thank you, for every time you tell someone, “Come in, get care, don’t worry about the bill.” Having that said to me when I was in crisis quite literally saved my life. It does matter, it does make a difference.
-T