Compliance Reporting Hotline
1-800-472-8868

EMTALA

Hospitals with dedicated emergency departments (ED) are required to take the following actions to comply with EMTALA:

• Adopt policies and procedures to comply with EMTALA requirements. For example, hospitals must have policies in place for when a particular specialty is not available or the on-call physician cannot respond due to circumstances beyond his/her control.
  
• Formally identify, in a document that is approved by the governing body of the hospital (i.e. medical staff by-laws) what individuals are qualified to perform a medical screening exam.
  

• Post signs in the ED specifying the rights of individuals with emergency medical conditions (EMC) and woman in labor who come to the ED and indicate on the signs whether or not the hospital participates in the State Medicaid Program. In order to comply, the signs must:

  • Specify the rights of individuals with an EMC and woman in labor who come to the ED for treatment;
  • Indicate whether the facility participates in the Medicaid Program;
  • The wording of the signs must be clear and in simple terms and languages that are understandable by the population served by the hospital; and,
  • The signs must be posted in a place likely to be noticed by all individuals entering the ED as well as those individuals waiting for examination or treatment.
    
• Maintain medical and other records related to individuals transferred to and from the facility for a period of five years from the date of transfer.
  
• Maintain a list of physicians who are on-call to provide services to patients with an EMC.
  

• Maintain a central log of individuals who come to the ED seeking treatment and indicate whether these individuals:

  • Refused treatment
  • Were denied treatment
  • Were treated, admitted, stabilized, transferred, or discharged

This central log includes, directly or by reference, patient logs from other areas of the hospital that may be considered “dedicated emergency departments” (such as labor and delivery) where a patient might present for treatment of an EMC.

• Provide for an appropriate medical screening exam (MSE).
  
• Provide necessary stabilizing treatment for EMC within hospital capabilities.
  

• Provide for an appropriate transfer of an unstabalized individual to another medical facility if:

  • The individual, after being informed of the risks and hospital obligations, requests a transfer.
  • A physician has signed the certification that the benefits of the transfer outweigh the risks of transferring the patient.
  • A qualified medical person (QMP) has signed the certification after a physician, in consultation with the QMP, has made the determination that the benefits of the transfer outweigh the risks.
  • Provide treatment to minimize the risks of transfer.
  • Send all pertinent records to the receiving hospital.
  • Obtain consent from the receiving hospital to accept the patient.
    
• MSE and/or stabilizing treatment is not to be delayed in order to inquire about payment status.
  
• Accept appropriate transfer of individuals with an EMC if the hospital has specialized capabilities and has the capacity to treat those individuals.
  
• Not penalize or take adverse action against a physician or QMP because the physician/QMP refuses to authorize the transfer of an individual with an EMC or against any individual who reports a violation of the EMTALA requirements.
  
• Report to CMS Regional Office immediately when a hospital receives an inappropriate transfer (within 72 hours of the occurrence).