If 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 doesn’t apply to hospital outpatient clinics that aren’t equipped to handle medical emergencies. But they’re required to refer patients to an emergency department in close proximity.
- If someone has an emergency medical condition, the hospital must provide care that stabilizes the person.
- If you are not in an emergency situation and you do not have insurance, the hospital is not legally obliged to treat you.
- Some health insurance companies deny emergency room claims if the person could have been treated at some other appropriate location.
- If you think that the hospital or your insurance company treated you unfairly, you can contact your state’s department of health.
What you’re entitled to
In a nutshell, the federal patient-dumping law entitles you to three things:
- Emergency care
- 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”?
The EMTALA describes an emergency medical emergency as one with acute symptoms of sufficient severity that needs immediate medical attention. Absence of immediate medical attention could result in:
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
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. Also, some health insurers deny emergency room claims if the person could have been cared at a “more appropriate” location, such as a doctor’s office or an urgent care center. So, it’s still a wise choice to see your doctor or a retail clinic for non-emergency care.
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 can’t be delayed while a hospital tries to obtain insurance pre-authorization.
EMTALA is still no guarantee
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.”
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
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, call your state’s department of health.