Emergency Medical Treatment and Labor Act

June 4, 2021 | Health System Risk Management


The federal Emergency Medical Treatment and Labor Act (EMTALA) (42 USC § 1395dd) was passed in 1986 as part of the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). EMTALA is commonly referred to as the "anti-patient-dumping law" because it was passed in response to the practice of some hospitals to deny emergency care to indigent or uninsured individuals or to transfer them to other facilities (usually "charity" or "safety net" hospitals) primarily because of their inability to pay for medical care. Before the law was passed, an estimated 250,000 patients were denied emergency medical care or were transferred inappropriately to public healthcare facilities each year because of their inability to pay for medical services (Ansell and Schiff). Since EMTALA was passed, hospital dedicated emergency departments (DEDs) have been prohibited from turning away people because of their insurance status or inability to pay; as a result, DEDs have become a safety net for many individuals seeking medical care.

Changes in the regulations promulgated by the Centers for Medicare and Medicaid Services (CMS), CMS's interpretive guidance, and court opinions have shaped how EMTALA is applied. Federal courts have interpreted EMTALA's scope and requirements in a variety of factual contexts, sometimes yielding conflicting opinions among circuits. Today EMTALA's reach includes the hospital campus, certain off-site facilities such as hospital-owned urgent care centers, and hospitals with specialized capabilities or facilities, even if they do not have EDs.

In the first 10 years of EMTALA, the federal government collected $1.8 million in EMTALA fines against hospitals and doctors (Wanerman). As the public's use of EDs grew in the 1990s, Congress allocated funding for the U.S. Department of Health and Human Services (HHS) to investigate complaints and for the U.S. Department of Justice to enforce the law. For the three-year period from fiscal years 1998 through 2000, the federal government collected $5.7 million in fines against hospitals and doctors, nearly three times more than in the previous 10 years (Ballard et al.). After fiscal year 1999, when EMTALA fines reached a peak of $2.7 million, the amounts of EMTALA fines collected annually dropped significantly (see Table. EMTALA Fines and Penalties for a tally of EMTALA fines levied against providers since 2014). As enforcement activity grew in the late 1990s, private causes of action escalated, and hospitals demanded ­relief from EMTALA obligations (Rosenbaum et al.).

An article from 2016 studied the settlement of claims for EMTALA violations between 2002 and 2015. It revealed that there were 192 settlements (14 per year). Fines against hospitals and physicians totaled $6,357,000 (averages $33,435 and $25,625 respectively). Of the 192 settlements, 184 (95.8%) were against hospitals and eight were against physicians. Most common settlements were for failing to screen for 144 (75%) and/or stabilize 82 (42.7%) emergency medical conditions. There were 22 (11.5%) cases of inappropriate transfer and 22 (11.5%) more cases in which the hospital failed to transfer the patient. Hospitals failed to accept an appropriate transfer in 25 (13.0%) cases. Patients were turned away from hospitals for insurance/financial reasons in 30 (15.6%) cases. There were 13 (6.8%) violations for patients in active labor. In 12 (6.3%) cases, the on-call physician refused to see the patient. In 28 (14.6%) cases the patient was inappropriately discharged. (Zuabi)

Recent studies have shed light on the types of violations that hospitals have experienced. For example, Terp et al. studied EMTALA violations involving psychiatric patients between 2002 and 2018. Of 230 civil monetary penalty settlements related to EMTALA during the study period, 44 (19%) were related to psychiatric emergencies. The average settlement for psychiatric-related cases was $85,488. The most commonly cited deficiencies for settlements involving psychiatric patients were failure to provide appropriate medical screening examination (84%) or stabilizing treatment (68%) or arrange appropriate transfer (30%). (Terp "Psychiatric")

Terp et al. also studied EMTALA violations involving obstetrical (OB) patients during the same time period as above. Settlements during the period included 39 (17%) that involved active labor and other OB emergencies. The proportion of settlements involving OB emergencies increased from 17% to 40% during this period. Seven (18%) settlements involved a pregnant minor. Most OB cases involved failure to provide screening exam (82%) and/or stabilizing treatment (51%). Failure to arrange appropriate transfer was common for OB patients (36%). Fifteen settlements (38%) involved a provider specifically directing a pregnant woman to proceed to another hospital, often by private vehicle. (Terp "Obstetric")

Additionally, Terp et al. studied EMTALA violations in which penalties were levied against individual physicians between 2002 and 2015. Of the 196 HHS Office of Inspector General (OIG) settlements related to violations of EMTALA, eight (4%) were levied against individual physicians. Seven of the eight penalties against individual physicians were imposed upon on-call specialists, including six who failed to respond to evaluate and treat a patient in the ED. One specialist failed to accept appropriate transfer of a patient requiring a higher level of care. The only penalty imposed on an emergency physician involved a case in which a provider repeatedly failed to provide a medical screening examination to a pregnant teen based on the mistaken belief that a pregnant minor could not be evaluated or treated absent parental consent. (Terp "Physicians")

HHS's OIG discloses penalties collected from hospitals and physicians for violations of EMTALA. These fines and penalties are those posted on the OIG website and may...

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