EMTALA Sample Cases for LLUMC Physicians

Prepared by the Office of Corporate Compliance and Approved by the Office of General Counsel

The following scenarios are hypothetical cases intended to supplement the EMTALA Q&A sheet issued by the Compliance Department with approval by the Office of General Counsel. These case examples are intended to provide education regarding the LLUH hospitals’ obligations under EMTALA transfers and do not represent actual events/occurrences. Additionally, these case examples should not be used as a substitute for professional legal advice.

SCENARIO 1: The ED physician asks about the emergency patient’s insurance coverage while discussing the transfer.

The ED physician receives a call, through the Transfer Center, requesting the transfer of an unstabilized emergency patient from XYZ Hospital. The ED physician asks the treating physician at XYZ Hospital what kind of insurance the patient has.

Did an EMTALA violation occur?
A: Yes. If the patient has an unstabilized emergency medical condition, the LLUH-Hospital may not make any inquiries regarding the patient’s financial status, insurance coverage, and/or payor source while discussing the transfer with XYZ Hospital.

SCENARIO 2: The patient’s emergency medical condition has been resolved, but the patient needs post-stabilization treatment.

The ED physician receives a call, through the Transfer Center, requesting a transfer of a patient from XYZ Hospital. The treating physician at XYZ Hospital informs the ED physician that the patient’s emergency medical condition has been resolved, but the patient needs post-stabilization higher level of care which XYZ Hospital does not have the capability to provide.

Is the LLUH-Hospital obligated to accept the transfer?
A: No. EMTALA ceases to apply once the patient’s emergency medical condition has been resolved. In this case, the LLUH-Hospital may appropriately discuss the patient’s ability to pay and/or insurance coverage with the transferring hospital and decide whether to accept or decline the transfer. The LLUH-Hospital may also appropriately seek prior authorization from the patient’s health plan, if applicable, related to the post-stabilization treatment.

Please note, however, that it is imperative that LLUMC confirm with the transferring hospital that the patient’s emergency medical condition has in fact been resolved before any inquiries and/or discussions into the patient’s financial status, insurance and/or ability to pay are initiated. 

Please note, however, that it is imperative that the LLUH-Hospital confirm with the transferring hospital that the patient’s emergency medical condition has in fact been resolved before any inquiries and/or discussions into the patient’s financial status, insurance and/or ability to pay are initiated.

SCENARIO 3: The treating physician at the transferring hospital and the ED physician at the LLUH-Hospital have contrasting judgments on the emergency patient’s stability for transfer.

An elderly patient presents to the ED of XYZ Hospital complaining of chest pain. The medical screening at XYZ Hospital indicates that the patient needs coronary bypass surgery, a service that XYZ Hospital does not have the capability to perform. XYZ Hospital contacts the Transfer Center requesting a transfer of the patient. The treating physician at XYZ Hospital indicates that the patient is stable for the transfer. However, the physician at an LLUH-Hospital believes that the patient is too unstable for the transfer and that the patient could die while in transit.

Which physician’s judgment prevails under EMTALA?
A: CMS has reaffirmed that the treating physician at the transferring hospital has the responsibility to determine whether an individual has an emergency medical condition, whether the condition is stabilized or resolved, and whether the individual’s condition is stabilized for purposes of transfer and discharge. Additionally, CMS and the courts have reaffirmed that the judgment of the treating physician requesting the transfer will be granted greater weight in determining the patient’s status and clinical needs.

SCENARIO 4: The transferring hospital has the capability to provide the specialized service required to stabilize the patient’s emergency medical condition, but the transferring hospital’s on-call physician is unavailable.

The ED receives a call, through the Transfer Center, from XYZ Hospital. XYZ Hospital wants to transport a 50 y/o male with chest pain who presented to their ED to a LLUH-Hospital. XYZ Hospital has done an EKG and performed blood work and the treating physician has determined that the patient needs the specialized services of a cardiologist to stabilize his condition. The ED physician knows that XYZ Hospital has a cardiologist on its staff, but the treating physician at XYZ Hospital indicates that XYZ Hospital’s cardiologist is not on-call and is unable to come to the hospital.

Is the LLUH-Hospital obligated to accept the transfer under EMTALA?
A: Under EMTALA provisions, if the LLUH-Hospital has the capability and capacity to provide the specialized care required to stabilize the emergency patient’s medical condition, the LLUH-Hospital is obligated to accept the transfer. After the transfer is affected and the patient is stabilized, LLUH-Hospital Administration can report XYZ Hospital to CDPH if they believe an EMTALA violation has occurred.

SCENARIO 5: The transferring hospital calls the LLUH-Hospital requesting a transfer, but there is another hospital with the capability to provide stabilizing treatment closer to the transferring hospital.

The ED physician receives a call, through the Transfer Center, requesting a transfer of an emergency patient from ABC Hospital. The treating physician at ABC Hospital informs the ED physician that the patient needs specialized care that ABC Hospital does not have the capability to provide. The ED physician knows that XYZ Hospital, which provides the required specialized care, is within closer proximity to ABC Hospital. The ED physician declines the transfer and tells the treating physician at ABC Hospital to transfer the patient to XYZ Hospital instead.

Did an EMTALA violation occur?
A: Yes. The transferring hospital may contact and request any hospital that may be able to provide treatment necessary to stabilize the emergency condition. There is no requirement that the transferring hospital contact the closest available hospital. EMTALA does not permit the receiving hospital to refuse an emergency transfer on the grounds that there is another receiving hospital closer to the transferring hospital that can provide the higher level of care required for the patient.

Could the ED physician have inquired as to why ABC Hospital called the LLUH-Hospital instead of XYZ Hospital?
A: Yes. The receiving hospital is not precluded from inquiring of the transferring hospital as to the availability of a closer hospital, as long as it is clearly communicated to the transferring hospital that the inquiry is made for information purposes to understand the circumstances of the transfer, and not as a condition or barrier to the acceptance of the transfer.

SCENARIO 6: The LLUH-Hospital provides the required specialized service but does not have any available bed.

ABC Hospital contacts the LLUH-Hospital regarding the transfer of a patient with an emergency medical condition. ABC Hospital does not have the capability to provide the specialized care required to stabilize the patient’s emergency medical condition, while the LLUH-Hospital does. However, due to high volume of patients, the LLUH-Hospital does not have any beds available for the patient.

May the LLUH-Hospital decline the transfer without violating EMTALA?
A: Yes. Under EMTALA, the receiving hospital is obligated to accept the transfer if it has both the capability AND capacity to provide the specialized care. In this case, the LLUH-Hospital does not have the capacity and can appropriately decline the transfer.

However, it is important to note that CMS will look at the LLUH-Hospital’s history to ascertain whether they customarily accommodate emergency patients in excess of its occupancy limits, i.e., by shifting patient room assignments or calling in additional staff. If the LLUH-Hospital typically provides services to emergency patients in excess of its service capacity in the manner so described, CMS may allege an EMTALA violation if the LLUH-Hospital denies treatment to a similar emergency patient, particularly if such patient lacks insurance.

It is important to note that CMS has indicated that when determining capacity and physician availability for care of an emergency patient, a consistent standard must be applied for patients who present directly to a LLUH-Hospital ED and to patients with emergency medical conditions requesting transfers from other Emergency Departments. This means that if a LLUH-Hospital customarily accommodates emergency patients that present directly to that Hospital’s ED in excess of its occupancy limits, i.e., by shifting patient room assignments or calling in additional staff, then the LLUH-Hospital must make the same type of accommodations for patients with emergency medical conditions requesting transfers from another Emergency Department.

Reference: California Hospital Association Hospital Compliance Manual, January 2010 1st edition