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Emergency room care: Know your rights

health insurance emergency roomIf you're in the emergency room, you’re probably too injured to haggle with hospital administrators about how you’re going to pay for your care -- especially if you don’t have health insurance. Fortunately, in 1986, Congress passed the Emergency Treatment and Labor Act (EMTALA) that prohibits 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.

What you're entitled to

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.

What is an "emergency medical condition"?

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:

  • There is inadequate time to make a safe transfer to another hospital before delivery.
  • A transfer might pose a threat to the health or safety of the woman or the unborn child.

Source: Social Security Act, SEC: Examination and Treatment for Emergency Medical Conditions and Women in Labor

What you're not entitled to

If you're not experiencing an emergency, and you don't have medical insurance or the ability to pay, the hospital emergency room is not legally required 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 coverage, the ultimate question of payment is between you and your insurance company. If you don't have health insurance, you will still be asked 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.

Public Citizen, a consumer watchdog group, claims that despite the law some hospitals continue refusing to provide basic treatment for patients who are unable to pay. "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, roughly $1.8 million in penalties were issued to hospitals and physician's offices nationwide.

The Office of Inspector General (OIG) has the authority to issue penalties under EMTALA. Those penalties may include:

  • Termination of Medicare agreement
  • Fines up to $50,000 for each violation
  • Lawsuits 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
  • 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

Since 2009, the Office of the Inspector General recorded 10 EMTALA violations. It doled out roughly $470,000 in fines to hospitals and doctors in Alabama, California, Florida, Illinois, Missouri and New Jersey.

The largest fine of $100,000, according to the OIG, was issued to Kaiser Foundation Hospitals in Santa Clara, California. The hospital agreed to pay $100,000 for allegedly violating the Patient Anti-Dumping Statute twice. According to OIG, Kaiser failed to provide appropriate medical screening examinations and stabilizing treatment for a 15-year old child that arrived at the emergency crying and complaining of severe abdominal pain. Kaiser discharged the patient and sent her to a pediatric physician group on the hospital's campus. In the second instance, a 12-year old boy returned to the emergency room after being sent home the night before. He was in pain, had a high fever and was lethargic with swollen eyes and face, but was discharged to the pediatric physician group on the hospital's campus. More than six hours after he went to the emergency department, he was admitted to Kaiser's Pediatric Intensive Care Unit where he died the next morning from staphylococcal sepsis, according to OIG.

What your health insurance company considers an emergency

Individual state regulations also have a bearing on the way you're treated in an emergency room, and upon your health insurance company'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.

Under the new health care reform law (Patient Protection and Affordable Care Act), insurance companies will be required to pay for emergency room care if a "prudent layperson, acting reasonably," would have considered the situation a medical emergency. In the past, this was only the case in some states. According to the National Association of Insurance Commissioners (NAIC), the new law requires insurers in all 50 states to adhere to the prudent layperson standard. The prudent layperson standard applies in all states for plan years beginning Sept. 23, 2010. If a policy has a plan year that begins on Nov. 1, 2010 the standard would not apply until that day. By Sept. 23, 2011, it will be effective for all plans that are not grandfathered, according to the NAIC.

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