If you're injured and in the emergency room, the
last thing you want to do is fight for treatment based on your ability
to pay. Fortunately, in 1986, the Emergency Treatment and Labor Act
(EMTALA) was passed to prohibit a practice commonly known as "patient
dumping." The act gives individuals the right to emergency care
regardless of their ability to pay. EMTALA was enacted as part of the
Consolidated Omnibus Budget Reconciliation Act (COBRA).
The federal law applies to hospitals that
participate in Medicare — and that's most hospitals in the United
States. Even so, EMTALA does not apply to hospital outpatient clinics
that are not equipped to handle medical emergencies, but they are
required to refer patients to an emergency department in close
proximity.
In a nutshell, the federal patient-dumping law
entitles you to three things: screening, emergency care and appropriate
transfers. A hospital must provide "stabilizing care" for a patient
with an emergency medical condition. The hospital must screen for the
emergency and provide the care without inquiring about your ability to
pay.
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According
to EMTALA provisions, a medical emergency involves acute symptoms of
sufficient severity (including severe pain) that the absence of
immediate medical attention could result in:
Placing the
health of the individual (or, with respect to a pregnant woman, the
health of the woman or her unborn child) in serious jeopardy. Serious impairment to bodily functions. Serious dysfunction of any bodily organ or part.
With respect to a pregnant woman who is having contractions, an emergency medical condition exists when:
Source: Social Security Act, SEC: Examination and Treatment for Emergency Medical Conditions and Women in Labor
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If you're not having an emergency, and you don't
have the ability to pay, the hospital emergency room does not have to
treat you. The hospital will most likely direct you to your own doctor
or a community health clinic.
The patient-dumping law was passed to ensure people in distress get necessary medical attention. If you have health insurance,
the ultimate question of payment is between you and your insurance
company. If you don't have health insurance, you will still have to
make payment arrangements with the hospital.
Once your condition has stabilized, the hospital has the option of moving you to another facility.
According to the U.S. Department of Health and
Human Services, the patient-dumping law also applies to HMOs that
illegally demand pre-authorization for emergency room visits. Emergency
room care cannot be delayed while a hospital tries to obtain insurance
pre-authorization.
The consumer watchdog group Public Citizen claims
that despite the law some hospitals keep refusing to provide basic
treatment for patients unable to pay for it. "It’s distressing that
this law has been in place and hospitals are still flouting it," says
Dr. Sidney Wolfe, director of Public Citizen’s Health Research Group.
"The government needs to do more to force hospitals to comply. People
shouldn’t be denied desperately needed emergency medical care when they
go to a hospital."
Public Citizen released a report that says more
than 500 hospitals were cited for illegally sending patients with
emergency conditions to other hospitals in the late 1990s. In the first
10 years following the law's enactment, $1.8 million in penalties were
issued to hospitals and physican's offices nationwide.
The Centers for Medicare & Medicaid Services
and the Office of Inspector General have the authority to issue
penalties under EMTALA. Those penalties may include:
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Termination of Medicare agreement.
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Hospital and physician fines up to $50,000 for each violation.
Lawsuit for personal injury in a civil court. -
A receiving facility affected by another hospital's failure to comply can sue the hospital to recover damages.
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A violation can be cited even if the
patient wasn't severely hurt. A violation cannot be cited if the
patient refuses examination and treatment, unless there is evidence
they were coerced.
In November 2008, the Office of the Inspector
General recorded eight violations of EMTALA. Among them, Baptist
Hospital in Florida paid $22,500 to settle allegations that it failed
to perform a medical screening on a man who was suicidal. The man told
emergency room personnel that his thoughts of suicide were getting
worse and he was told that he would have to continue to wait in the
waiting room. He immediately left the building and lacerated his right
arm. In Los Angeles, Methodist Hospital settled allegations of patient
dumping after discharging numerous homeless patients without the proper
care. The hospital was required to pay $215,000 for recuperative care
beds at a local homeless shelter, $5,000 in civil penalties and $20,000
in investigative costs. The total payout was $240,000.
Individual state regulations also have a bearing on
the way you're treated in an emergency room, and upon your health
insurer's decision to pay for that treatment. The federal law allows
you basic rights, and your state laws might provide you with some
additional ones.
If you feel you have been treated unfairly, either
by the hospital or by your insurance company, try calling your state's
department of health. If you feel your insurance company is unjustly
denying payment, try your state's insurance department.
Some states also require insurance companies to pay
for emergency room care if a "prudent layperson, acting reasonably,"
would have considered the situation a medical emergency. Forty-two
states enforce a prudent layperson standard. All states except Alaska,
California, Florida, Montana, New Hampshire, New Jersey, Rhode Island
and Wyoming have the prudent layperson standard, according to the
National Conference of State Legislatures.
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