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?
Canadian Pharmacy
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.
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I’ve been reading along for a while now. I just wanted to drop you a comment to say keep up the good work.