EMTALA — A Guide To Laws - California Hospital Association

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EMTALA — A Guide toPatient Anti-DumpingLaws20189th EditionWritten byM. Steven LiptonHooper, Lundy & Bookman, PCPublished byCalifornia Hospital Association

CHA PublicationsSeveral helpful publications are available through CHA including: California Health InformationPrivacy Manual Hospital Financial Assistance Policiesand Community Benefit Laws California Hospital Compliance Manual Mental Health Law California Hospital Survey Manual —A Guide to the Licensing & CertificationSurvey Process Minors & Health Care Law Consent Manual EMTALA — A Guide toPatient Anti-Dumping Laws Guide to Release of Patient Information Model Medical Staff Bylaws & Rules Record and Data Retention Schedule The Cal/OSHA Safe Patient HandlingRegulation The California Guide to PreventingSharp Injuries Healthcare Workplace Violence PreventionPlus numerous human resource and volunteer publications.Ordering InformationFor more information, visit CHA online at www.calhospital.org/publicationsThis publication is designed to produce accurate and authoritative information with regard to the subject matter covered.It is sold with the understanding that CHA is not engaged in rendering legal service. If legal or other expert assistance isrequired, the services of a competent professional person should be sought. 1999, 2000, 2001, 2003, 2004 by the California Healthcare Association 2007, 2009, 2012, 2018 by the California Hospital AssociationAll rights reserved. First edition 1999.Ninth edition 2018.No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means,electronic, mechanical, photocopying, recording, or otherwise, without the prior written approval of:California Hospital AssociationATTN: Publishing1215 K Street, Suite 800Sacramento, CA 95814However, hospitals that are members of the California Hospital Association may use the Model Hospital Compliance Plan,model forms, signs and handouts as templates in developing their own plan, forms, signs and handouts.It is the intent of CHA and HLB to strictly enforce this copyright.Published by the California Hospital Association.Printed in the United States of America.Liz Mekjavich, Vice President, Publishing and EducationLois J. Richardson, Esq., Vice President and Counsel, Privacy and Legal Publications/EducationBob Mion, Director, Publishing and MarketingEmily Stone, Publishing Manager

Quick ReferenceINTRODUCTIONAUTHOR ACKNOWLEDGMENTSWHERE TO FIND LAWS REFERENCED IN THE MANUALLIST OF ACRONYMSCHAPTERSChapter 1Overview of Patient Anti-Dumping LawsChapter 2When and Where Does EMTALA Begin and End?Chapter 3Medical Screening ExaminationsChapter 4Financial Considerations — EMTALA and Managed CareChapter 5Transferring or Discharging an Emergency PatientChapter 6EMTALA and Psychiatric Emergency PatientsChapter 7Obligations of Receiving HospitalsChapter 8Patient Refusal of Stabilizing Treatment or TransferChapter 9Maintenance pf the Central LogChapter 10Required SignageChapter 11Physician On-Call ResponsibilitiesChapter 12Reporting Patient-Dumping ViolationsChapter 13Regulatory Enforcement of EMTALAChapter 14Private Actions to Enforce EMTALAChapter 15Quality Improvement and Risk ManagementChapter 16Application of EMTALA to Disasters and Public Health EmergenciesINDEXAPPENDIXESAppendix AEMTALA StatuteAppendix BEMTALA and Emergency-Related Federal RegulationsAppendix CEMTALA Interpretive Guidelines (Part II: Responsibilites of MedicareParticipating Hospitals in Emergency Cases)Appendix DCalifornia Hospital Licensing Laws on EmergencyServices and CareAppendix ECoP for Emergency Services: Hospital Interpretive Guidelines

CHAEMTALA — A Guide to Patient Anti-Dumping Laws 2018Appendix FKnox-Keene Act ProvisionsAppendix GMedicare Advantage RegulationsAppendix HSpecial Advisory BulletinAppendix IEMTALA Enforcement ChartAppendix JHospital Records Subject to EMTALA Enforcement SurveyAppendix KInvestigative Procedures for EMTALA Surveyors(Part I of EMTALA Interpretive Guidelines)Appendix LSample Survey Tools for Patient Transfers and MedicalScreening ExaminationsAppendix MAn Explanation of the Scope of RN Practice IncludingStandardized ProceduresAppendix NPolicies Recommended for EMTALA ComplianceAppendix OModel Hospital Policy on Compliance with EMTALAAppendix PCHA Transfer Forms and Model SignageAppendix QCMS Survey and Certification Memorandum 08-08: Requirementsfor Off-Campus Emergency Departments (Jan. 11, 2008)Appendix RCMS Survey and Certification Memorandum 09-52: EMTALAOptions in a Disaster (Aug. 14, 2009)Appendix SSample Transfer AgreementAppendix TSample Transfer Checklist and Script for AcceptingEmergency PatientsAppendix UCDPH All-Facility Letter 12-17 (May 17, 2012)Appendix VCMS Letter Regarding Transfer of Patients to CrisisStabilization UnitsAppendix WEMTALA Physician Review WorksheetAppendix XCMS Survey and Certification Memorandum 14-06:EMTALA Requirements & Conflicting Payor Requirements orCollection Practices (Dec. 13, 2013)Appendix YCMS Survey and Certification Memorandum 13-38: Critical AccessHospital Emergency Services and Telemedicine (June 7, 2013)Appendix ZCMS Survey and Certification Memoranda 06-21 and 07-20:Detaining EMS Personnel and Equipment (July 13, 2006 andApril 27, 2007)Appendix AACMS Survey and Certification Memoranda 15-10 and 15-24:EMTALA and Ebola (Nov. 21, 2014 and Feb. 13, 2015)

IntroductionEMTALA — A Guide to Patient Anti-Dumping Laws, 9th edition (2018), provides guidanceto hospitals and physicians on compliance with the Emergency Medical Treatment andLabor Act (EMTALA). Where applicable, the EMTALA manual also addresses Californiahospital licensing, involuntary commitment and managed care laws regarding the provision ofemergency services and post-stabilization care.Since the adoption of the initial EMTALA regulations in 1994, the U.S. Department of Healthand Human Services (HHS) has committed extensive resources to enforcing EMTALA.The Centers for Medicare & Medicaid Services (CMS) is charged with the administrativeinterpretation and enforcement of EMTALA. As discussed in a 2001 HHS Office of InspectorGeneral (OIG) report, the number of EMTALA investigations and their outcomes vary widelyby CMS region; however, administrative enforcement by CMS Region IX (California, Arizona,Hawaii and Nevada) has been among the more active in the nation. In addition, the OIG hasthe authority to enforce EMTALA against hospitals and physicians by imposing civil moneypenalties or exclusion from the Medicare and Medicaid programs. In 2017, the civil penaltiesfor an EMTALA violation were updated for inflation which increased sanctions to over 100,000 for an EMTALA violation (more than 50,000 for a hospital under 100 beds).Despite three decades of experience with EMTALA, there is still considerable confusion byhospitals, physicians, state survey agencies, and even some CMS officials, on the scope andapplication of the law. In 1994 and 2000, CMS expanded the scope of EMTALA; in 2003,CMS both limited and expanded the scope of EMTALA in an overhaul of the 1994 and 2000regulations. Between 2004 and 2013, CMS periodically amended the EMTALA regulationsin piecemeal fashion. The EMTALA Interpretive Guidelines issued by CMS were last updatedin 2010, and have been supplemented by several Survey and Certification memoranda onvarious topics related to EMTALA complianceDespite the efforts to clarify EMTALA, there are still several long-standing areas of confusion.These include the application of EMTALA to hospitals that do not operate a licensed ororganized emergency department, and to hospital urgent care centers and other servicesthat are held out for both scheduled and drop-in patients. As to emergency departmentoperations, there are still questions about the scope of an appropriate medical screeningexamination, the meaning of “stabilized” and the relevance of “clinical stability” to a transfer,the obligations of receiving hospitals, and the standards for on-call coverage. There is theincreasing struggle, if not crisis, in the overlay of EMTALA obligations to state involuntarycommitment laws and regional treatment networks for psychiatric patients that include a mixof hospitals and ambulatory settings.

CHAEMTALA — A Guide to Patient Anti-Dumping Laws 2018Hospitals are also subject to court decisions establishing interpretations of EMTALA, someof which vary from the EMTALA regulations or the CMS Interpretive Guidelines. As discussedin chapter 14, “Private Actions to Enforce EMTALA,” courts have issued decisions on thestandard of proof for an EMTALA violation, the application of EMTALA to inpatients andto individuals in nonhospital-owned ambulances en route to a hospital, the scope of anappropriate medical screening examination, the determination of a dedicated emergencydepartment and the obligations of a receiving hospital to accept emergency patient transfers.The EMTALA manual is designed to summarize the EMTALA obligations for hospitals andphysicians, and answer the most frequently asked questions. Readers familiar with EMTALAknow that the interpretation of EMTALA is fast-changing (and at times, mind-numbing andfrustrating). The 9th edition includes updates to the EMTALA regulations, the InterpretiveGuidelines and CMS program memoranda through October 2017.The EMTALA manual is written for hospital staff and physicians; therefore, the text does notinclude footnotes identifying the sources for the content. To assist readers, the appendicesto the manual include the EMTALA statute and regulations, the Interpretive Guidelines andCalifornia hospital and managed care laws on emergency and post-stabilization services.Additional appendices include a model hospital compliance policy, a receiving hospital transferchecklist and other materials. References to these materials are marked with a F throughoutthe manual.The EMTALA manual is generally limited to EMTALA and California laws governing the provisionof emergency services. It does not address numerous other laws and legal obligationsapplying to hospitals, physicians and other health care personnel in providing emergencycare. These include hospital licensing laws for emergency departments; professional practiceacts; accreditation standards; consent and privacy laws; reimbursement issues; requirementsof regional emergency medical service networks; the rights of persons subject to involuntarydetention; trauma standards; and other laws that apply to emergency services and personnel.The EMTALA manual is limited to the obligations to comply with EMTALA and other emergencyservice laws. Hospitals, physicians and other caregivers are encouraged to consider ethical,philosophical (e.g., mission and values) and industry standards in making decisions related toemergency services and care, whether or not implicated by EMTALA or other laws.

AuthorAcknowledgmentsThe nine editions of the EMTALA manual have been produced with the assistance of manypeople. Special thanks for prior contributions to the EMTALA manual from Susan Harris,Carole Klove, Debbie Jaret, Allen Briskin, Gaby Goldstein (especially for assistance withthe 7th edition), Alicia Macklin (especially for assistance with the 9th edition), consultationfrom Clark Stanton, Dorel Harms, Mark Cohen, and Peggy Nakamura, and assistance fromMary Barker, Liz Mekjavich, Bethany Boom, Emily Stone, Bob Mion and Amy Larsen of theCalifornia Hospital Association. The manual would also not be “new and improved” withoutthe special efforts of Lois Richardson. Chapter 6, the application of EMTALA to psychiatricemergency patients, would not be possible without the knowledge and experience, andgracious mentoring, from Sheree Lowe, Linda Garrett and Mike Phillips. In addition, the authorhas received informal guidance over many years from representatives of CMS, including Dr.Charlotte Yeh, Ken Simpson, Ruth Patience, Gretchen Kane, Rufus Arther and Kelly Valente.And, as always, special thanks to Robbin and Zach.

Where to Find LawsReferenced in theManualAll of the laws discussed in EMTALA — A Guide to Patient Anti-Dumping Laws can be foundon the Internet.FEDERAL LAWA federal statute is written by a United States Senator or Representative. It is voted on by theUnited States Senate and the House of Representatives, and then signed by the President.A federal statute is referenced like this: 42 U.S.C. Section 1395. “U.S.C.” stands for “UnitedStates Code.” Federal statutes may be found at www.gpo.gov/fdsys or at www.law.cornell.edu.A federal regulation is written by a federal agency such as the U.S. Department of Healthand Human Services or the U.S. Food and Drug Administration. The proposed regulation ispublished in the Federal Register, along with an explanation (called the “preamble”) of theregulation, so that the general public and lobbyists may comment on it. The federal agencymust summarize and respond to each comment it receives on the proposed regulation. Theagency may or may not make changes to the proposed regulation based on the comments.The final regulation is also published in the Federal Register. A federal regulation is referencedlike this: 42 C.F.R. Section 482.1 or 42 C.F.R. Part 2. “C.F.R.” stands for “Code of FederalRegulations.” Federal regulations may be found at www.gpo.gov/fdsys or at www.ecfr.gov. The preamble, however, is only published in the Federal Register and not in the Codeof Federal Regulations. The Federal Register may be found at www.gpo.gov/fdsys or atwww.federalregister.gov.The Centers for Medicare & Medicaid Services publishes its Interpretive Guidelines forsurveyors on the internet. They may be found at als/Internet-Only-Manuals-IOMs.html (click on Publication 100-07, “StateOperations Manual,” then “Appendices Table of Contents”). There are several appendicesthat hospitals will find useful, for example, A (hospitals), AA (psychiatric hospitals), V(EMTALA), and W (critical access hospitals).A federal law must be obeyed throughout the United States, including in California, unless thefederal law expressly states otherwise. As a general rule, if a federal law conflicts with a statelaw, the federal law prevails, unless the federal law expressly states otherwise.If there is no conflict, such as when one law is stricter but they don’t actually conflict witheach other, both laws generally must be followed. For example, under the Health InsurancePortability and Accountability Act of 1996 (HIPAA), the federal law states that providers mustconform to whichever provision of federal or state law provides patients with greater privacyprotection or gives them greater access to their medical information.

CHAEMTALA — A Guide to Patient Anti-Dumping Laws 2018STATE LAWA state statute is written by a California Senator or Assembly Member. It is voted on bythe California Senate and Assembly, and then signed by the Governor. A state statute isreferenced like this: Civil Code Section 56 or Health and Safety Code Section 819. Statestatutes may be found at www.leginfo.legislature.ca.gov. Proposed laws (Assembly Bills andSenate Bills) may also be found at this website.A state regulation is written by a state agency such as the California Department of PublicHealth or the California Department of Managed Health Care. A short description of theproposed regulation is published in the California Regulatory Notice Register, more commonlycalled the Z Register, so that the general public and lobbyists may request a copy of the exacttext of the proposed regulation and comment on it. The state agency must summarize andrespond to each comment it receives on the proposed regulation. The agency may or maynot make changes to the proposed regulation based on the comments. A notice that the finalregulation has been officially adopted is also published in the Z Register. The Z Register maybe found at www.oal.ca.gov/notice register.htm.A state regulation is referenced like this: Title 22, C.C.R., Section 70707. “C.C.R.” stands for“California Code of Regulations.” State regulations may be found at www.calregs.com.A state law must be obeyed in California only. As a general rule, if a California law conflictswith a federal law, the federal law prevails, unless the federal law expressly states otherwise.(If there is no conflict, such as when one law is stricter but they don’t actually conflict witheach other, both laws generally must be followed.)

List of AcronymsABNAdvance Beneficiary Notice of NoncoverageAIDSAcquired Immune Deficiency SyndromeAFLAll Facility Letter (issued by CDPH)AIIAirborne infection isolationAirIDAirborne Infectious DiseaseALJAdministrative Law JudgeAMAAgainst medical adviceATDAerosol transmissible diseaseBRNBoard of Registered NursingCAHCritical access hospitalCDCCenters for Disease Control and PreventionCCPCommunity call planCDPHCalifornia Department of Public HealthCHACalifornia Hospital ASsociationCFRCode of Federal REgulationsCMSCenters for Medicare & Medicaid ServicesCoPMedicare Conditions of ParticipationCSUCrisis stabilization unitDABDepartmental Appeals BoardDEDDedicated emergency departmentDHCSCalifornia Department of Health Care ServicesDHMCCalifornia Department of Managed Health CareEDEmergency departmentEMCEmergency medical conditionEMSEmergency medical servicesEMTEmergency medical technician

CHAEMTALA — A Guide to Patient Anti-Dumping Laws 2018EMTALAEmergency Medical Treatment and Active Labor ActFed. Reg.Federal RegisterGAOGeneral Accountability OfficeHCFAHealth Care Financing Administration (the former name of CMS)HHSU.S. Department of Health and Human ServicesHMOHealth maintenance organizationHSAGHealth Services Advisory GroupICUIntensive care unitIPAIndependent practice associationIRSInternal Revenue ServiceLPSLanterman-Petris-Short ActLWBSLeft without being seenMAMedicare AdvantageMICRAMedical Injury Compensation Reform ActMRIMagnetic resonance imagingMSEMedical screening examinationOBObstetricsOBRAOmnibus Budget Reconciliation ActOCROffice for Civil Rights (part of HHS)OIGOffice of Inspector General (part of HHS)OSHAOccupational Safety and Health AdministrationOSHPDOffice of Statewide Health Planning and DevelopmentPHFPsychiatric health facilityQAPIQuality assurance/performance improvementQIOQuality improvement organizationS&CSurvey and Certification (Medicare)TAGEMTALA Technical Advisory Group

1 Overview of PatientAnti-Dumping LawsI.EMTALA Overview And History 1.1A.The EMTALA Statute 1.1B.The EMTALA Regulations 1.1C.The EMTALA Interpretive Guidelines 1.1D.Special Advisory Bulletins and Other Guidance 1.2E.Enforcement and Penalties 1.2F.  EMTALA Committees and Reports 1.3Office of Inspector General 1.3General Accountability Office 1.4EMTALA Technical Advisory Group 1.4II.EMTALA Compliance 1.5III. State Laws 1.5IV. Definitions 1.6A.Campus of a Hospital 1.6B.Capacity 1.6C.Comes to the Emergency Department 1.6D.Consultation 1.7E.Dedicated Emergency Department 1.7F.Emergency Medical Condition 1.7G.Emergency Services and Care 1.8H.Hospital Property (also referred to as the “Campus of a Hospital”) 1.8I.  Labor 1.9J.  Psychiatric Emergency Medical Condition 1.9K.  To Stabilize 1.9L.  Stabilized 1.10M.Transfer 1.10N.  Within the Capability of the Facility 1.10CALIFORNIA HOSPITAL ASSOCIATIONChapter 1 — Contents

1 Overview of PatientAnti-Dumping LawsI.EMTALA OVERVIEW AND HISTORYA. The EMTALA StatuteThe Emergency Medical Treatment and Labor Act (EMTALA) was enacted by Congress asa part of the Consolidated Omnibus Budget Reconciliation Act of 1986 to ensure accessto emergency services. The statute was amended in 1988, 1989, 2003 and 2011. EMTALAapplies to anyone who presents for emergency services to a hospital that participates inthe Medicare program (including psychiatric hospitals). The EMTALA statute is included asAppendix A.EMTALA was enacted in response to studies that found that indigent emergency patientshad been turned away from hospitals for necessary services or transferred (i.e., “dumped”)to public and charity hospitals in an unstabilized condition. Although EMTALA was passedto mandate access to emergency services by the indigent, Congress applied the EMTALArequirements to all patients regardless of financial or insurance status. In general, both thefederal regulatory agencies and the courts have defined the primary objectives of EMTALAas twofold: to enhance access by all persons to emergency services and to prohibitdiscrimination in the provision of emergency services to persons presenting with the same orsimilar types of conditions.B. The EMTALA RegulationsThe initial EMTALA regulations were published in draft form in 1988, and issued as interimfinal regulations on June 22, 1994. On April 7, 2000, the regulations were amended to applythe EMTALA obligations to off-campus hospital services. In September 2003, the Centers forMedicare & Medicaid Services (CMS) published further changes to the EMTALA regulations,repealing part of the 2000 regulations and clarifying the application of EMTALA to emergencypatients, outpatients and inpatients. Since 2004, CMS has amended the EMTALA regulationsin piecemeal fashion in 2006, 2007, 2008 and 2009. The current regulations are included asAppendix B.C. The EMTALA Interpretive GuidelinesCMS has adopted Interpretive Guidelines as part of the Medicare State Operations Manual toprovide guidance for federal and state surveyors in their enforcement of EMTALA. Althoughthe Interpretive Guidelines are not regulations, they are considered the official interpretation ofEMTALA by CMS and are used by California Department of Public Health (CDPH) surveyorsand CMS regional offices in enforcement of the EMTALA obligations. The most recent updateto the Interpretive Guidelines was July 16, 2010; the Interpretive Guidelines are included asAppendix C.NOTE: The Interpretive Guidelines are organized by “tag numbers,” each of whichcorresponds to a CMS regulation that establishes the rules for EMTALA. The tag numbersCALIFORNIA HOSPITAL ASSOCIATION1.1

CHAEMTALA — A Guide to Patient Anti-Dumping Laws 2018beginning with the letter “A” are applicable to hospitals and the tag numbers beginning withthe letter “C” are applicable to critical access hospitals. Each tag number has four digits, withthe number “2” at the beginning of each tag number.D. Special Advisory Bulletins and Other GuidanceIn November 1999, CMS and the Office of Inspector General (OIG) released a final SpecialAdvisory Bulletin on EMTALA and managed care. The Bulletin discusses the rules onseeking health plan authorization prior to the medical screening examination (which wereadded to the EMTALA regulations in 2003), dual staffing of emergency departments andrecommended patient registration practices to minimize violations of EMTALA. The Bulletinis discussed in chapter 4, “Financial Considerations — EMTALA and Managed Care,” and isincluded as Appendix H.From time to time, CMS issues Program Memoranda on various subjects relatingto EMTALA obligations. Most of these memoranda have been incorporated into theInterpretive Guidelines (see Appendix C). This manual includes the latest CMS guidance onCritical Access Hospital on-call compliance with EMTALA (Appendix Y), conflicting payorrequirements (Appendix X), and Ebola implications for EMTALA (Appendix AA). Thesememoranda are also described in detail in applicable chapters of this manual.E. Enforcement and PenaltiesThe EMTALA obligations are a condition of the Medicare provider agreement (rather than aCondition of Participation), thereby permitting CMS to terminate a provider upon a confirmedviolation of EMTALA. As described in chapter 13, “Regulatory Enforcement of EMTALA,” thefederal agencies charged with ensuring EMTALA compliance are CMS and the OIG.CMS has the authority to conduct complaint and enforcement surveys for EMTALAcompliance, and to terminate a hospital’s Medicare provider agreement upon confirming oneor more violations of EMTALA.Under the EMTALA statute (Appendix A), the OIG has the authority to impose civil moneypenalties up to 50,000 against hospitals and physicians ( 25,000 for hospitals with lessthan 100 beds), and/or to exclude a hospital or physician from the Medicare and Medicaidprograms for violations of EMTALA that are “gross and flagrant or repeated.” In December2016, the OIG issued final regulations updating the amount of civil money penalties, includingEMTALA fines. Effective in 2017, the OIG may now impose civil penalties up to 104,826against hospitals and physicians ( 52,414 for hospitals with less than 100 beds) for anEMTALA violation. The maximum amount of the fines is subject to annual adjustment forinflation.The regional quality improvement organization (QIO) is responsible for assisting CMS and OIGreview patient stabilization and other medical matters pertaining to the delivery of emergencycare and services.For hospitals that have community service obligations under the Hill-Burton Act, the Office forCivil Rights (OCR) will follow up on violations of EMTALA confirmed by CMS with a requestfor copies of EMTALA compliance, transfer, admission and other hospital policies.1.2CALIFORNIA HOSPITAL ASSOCIATION

Chapter 1 — Overview of Patient Anti-Dumping LawsCHAF. EMTALA Committees and ReportsSince 2001, there have been a number of committees and governmental agencies thathave issued reports on EMTALA, including reports regarding compliance by hospitals andphysicians with EMTALA standards, the enforcement process and the overall effect of the law.Office of Inspector GeneralIn January 2001, the OIG released two reports on EMTALA: “Survey of Hospital EmergencyDepartments” and “The Enforcement Process.”The OIG’s “Survey of Hospital Emergency Departments” made the following findings:1.Emergency department personnel are familiar with the EMTALA requirements, butmany are unaware of recent policy changes.2.Training increases EMTALA familiarity for all staff; unfortunately, on-call specialistsand staff in high-volume emergency departments are less likely to receive training.3.Hospital staff report that hospitals generally comply with EMTALA, but someexpress concerns about compliance.4.Hospital staff believe that some aspects of EMTALA are unclear or questionable.5.Hospital staff believe that while EMTALA may help protect patients, it also maycontribute to a hospital’s administrative and financial problems.6.Investigations, many of which do not confirm violations, often prompt changes informs and procedures.7.Managed care creates special problems for hospitals in complying with EMTALA.8.Hospitals have difficulty staffing on-call panels for some specialists.The OIG report made three conclusions:1.CMS should use a variety of methods to communicate important policy changes,including e-mail and the Internet.2.CMS should support legislation that compels managed care plans to reimbursehospitals for EMTALA-related services, including screening exams that do notreveal the presence of an emergency medical condition.3.Uncompensated care and on-call panels are very complex problems that mayrequire action at the federal, state and local levels as well as by private entities.The OIG reported that CMS concurred with its recommendations.In “The Enforcement Process” report, the OIG issued the following findings on the EMTALAenforcement process:1.The EMTALA enforcement process is compromised by long delays and inadequatefeedback.2.The number of EMTALA investigations and their ultimate disposition vary widely byCMS region and year.3.CALIFORNIA HOSPITAL ASSOCIATIONPoor tracking of EMTALA cases impede oversight.1.3

CHAEMTALA — A Guide to Patient Anti-Dumping Laws 20184.Peer review is not always obtained before CMS considers terminating a hospital formedical reasons.The OIG report recommended that CMS increase its oversight of the regional offices

EMTALA — A Guide to Patient Anti-Dumping Laws, 9th edition (2018), . applying to hospitals, physicians and other health care personnel in providing emergency care. These include hospital licensing laws for emergency departments; professional practice . emergency patients, would not be possible without the knowledge and experience, and

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