DEPARTMENT: Governmental Operations Support / POLICY DESCRIPTION: Collection of Financial Information under EMTALA
PAGE:1 of 5 / REPLACES POLICY DATED: 9/15/1998; 01/12/1999
EFFECTIVE DATE: January 28, 2005 / REFERENCE NUMBER: GOS.BILL.002
SCOPE: All Company hospitals with an emergency department. Specifically, personnel that obtain financial information from an individual covered under EMTALA in the following departments either located on campus or in departments that meet the definition of a “dedicated emergency department” located off campus.
Business Office Nursing
Admitting/Registration Ancillary Services
Finance Health Information Management

Administration Utilization Review Management

Service Centers Dedicated Emergency Departments located off-campus
All Clinical and Non-Clinical Departments located on hospital property, including but not limited to Dedicated Emergency Departments located on-campus
PURPOSE: To establish guidelines regarding the collection of financial information from an individual who is not a patient that comes to a dedicated emergency department (DED) with a medical condition or presents on hospital property other than a DED with an emergency medical condition (EMC) as required by the Emergency Medical Treatment and Active Labor Act (“EMTALA”), 42 U.S.C., Section 1395dd and all Federal regulations and interpretive guidelines promulgated thereunder.
POLICY: Collection of financial information from an individual covered under the EMTALA obligations must be performed in accordance with this policy.
Under EMTALA, the hospital with an emergency department must provide to an individual that is not a patient who “comes to the emergency department” an appropriate medical screening examination (MSE) within the capability of the hospital’s emergency department to determine whether or not an EMC exists. The EMTALA obligations are triggered when there has been a request for medical care by an individual within a DED or when an individual requests care for an EMC on hospital property, other than in a DED. If an EMC is determined to exist, the hospital must also provide any necessary stabilizing treatment or an appropriate transfer.
Once EMTALA is triggered, hospitals must not delay in providing an MSE or, if an emergency medical condition is determined to exist, necessary stabilization treatment. Hospitals may follow reasonable registration processes for individuals covered under EMTALA which may include requesting information about insurance and requesting payment of copays, deductibles or a deposit for the encounteras long as it does not delay the MSE or stabilization or unduly discourage the individual from remaining for further examination.
Some states have separate emergency services laws that may apply additional legal requirements to the MSE, diagnostic testing, or stabilizing emergency medical treatment. Consult with your Operations Counsel to identify and comply with any such additional legal mandates. Hospitals in states with additional requirements must develop policies that address the state-specific requirements that exceed the requirements of this policy.
PROCEDURE:
Each hospital that participates in the Medicare program and provides emergency medical services must develop policies and procedures to insure compliance with EMTALA requirements relating to the collection of financial information for individuals covered under EMTALA. Such policies should contain the provisions outlined below. Please refer to the EMTALA - Medical Screening Policy, LL.EM.001, for the basic obligations of EMTALA and a complete list of definitions pertaining to this policy.
  1. Application. EMTALA obligations do not apply to individuals who have begun to receive outpatient services as part of an encounter, other than an encounter that the hospital is obligated by EMTALA to provide. EMTALA is also not applicable to an inpatient that was admitted for a non-emergency diagnosis or treatment. Existing Medicare hospital Conditions of Participation and relevant state laws protectindividuals who are already patients of a hospital and who experience emergency medical conditions.
  1. Equality of Care. The hospital, regardless of size or patient mix, must provide an MSE and stabilizing treatment within the scope of its capabilities and shall not discriminate against any individual because of diagnosis (e.g., labor, AIDS), financial status (e.g., uninsured, Medicaid), race, color, national origin, or handicap.
  2. A different level of care must not exist based on payment status, race, national origin, etc. for a screening process that is reasonably calculated to determine whether an emergency medical condition exists.
  3. An MSE and, if necessary, stabilization treatment may not be refused by the hospital for any reason, even if a managed care plan refuses to authorize treatment or to pay for services.
  1. Payment Inquiries. An MSE or stabilization treatment may not be delayed by the hospital personnel in order to: i) Inquire about an individual’s ability to pay; ii) Inform the individual that he or she must pay for his/her care if they choose to be treated; iii) Perform insurance verification and authorization; or iv) Inform the individual that his/her care will be free or at a lower cost if they transfer to another facility.
a. The registrar may request co-pays, deductibles or deposits for the current encounter provided such request does not delay the MSE or necessary stabilizing treatment. An example of an appropriate request is, “We are planning to conduct a medical screening exam and provide any necessary stabilizing treatment. While we are waiting for your exam and possible treatment, we’d like to go ahead and collect your co-pay and/or deductible or a payment deposit (as applicable).”
b. The registrar must refrain from making any remarks, which an individual might interpret to mean services may not be provided based on his/her ability to pay. For example, the registrar must refrain from stating, “We don’t accept ABC insurance here.”
  1. Information from the health plan. The hospital may seek other information from the individual’s health plan about the individual such as medical history. In the case of an individual with an EMC, once the hospital has conducted the MSE and has initiated stabilizing treatment, it may seek authorization for all services from the plan as long as doing so does not delay or interfere with the stabilizing treatment.
  1. Financial liability inquiries. Individuals who inquire about financial responsibility for medical care in a DED or for emergency care on hospital property other than a DED should receive a response by a staff member who has been well trained to provide information regarding potential financial liability. The staff member who provides information on potential financial liability should clearly inform the individual that the hospital would provide an MSE and any necessary stabilizing treatment, regardless of his or her ability to pay. Individuals who believe that they have an EMC should be encouraged to remain for the MSE.
  1. Satisfying EMTALA. The hospital has satisfied its obligations to an individual under EMTALA if:
  2. The MSE is appropriately conducted and does not reveal that an EMC exists; or
  3. The hospital has screened an individual and found that the individual has an EMC and admits that individual as an inpatient in good faith in order to stabilize the EMC; or
  4. The hospital has screened an individual and found that the individual has an EMC and appropriately transfers that individual to another facility for treatment of the EMC; or
  5. The hospital has screened an individual and found that the individual has an EMC, has stabilized the EMC and discharges that individual.
PROCESS:
Registration procedures should be developed to ensure the guidelines outlined above are included in day to day processes and basic identifying information is obtained in order to utilize the order entry systems and expedite an individual’s care, such as:
  1. When an individual requests, or has a request made on his behalf for, medical care within a DED or when an individual requests, or has a request made on his behalf for, care for an emergency medical condition on hospital property other than a DED, the MSE and necessary stabilization will begin in accordance with the DED’s protocols.
  1. The registrar may obtain the information necessary to perform a routine registration from the individual or from a source other than the individual (e.g., authorized next of kin), provided such request does not delay the MSE or any necessary stabilizing treatment. Otherwise, this financial information should be obtained after the individual has received an MSE and any necessary stabilization treatment. The individual may be informed of his/her potential financial liability after the determination that the individual does not have an EMC or the provision of any necessary stabilization treatment.
  1. Neither the performance of the MSE nor the provision of stabilizing treatment will be conditioned on an individual’s completion of a financial responsibility form, an advance beneficiary notification form, nor payment of a co-payment or deposit for any services rendered. The obtainingof any applicable Advance Beneficiary Notice must follow an MSE and any necessary stabilization treatment.
  1. If the MSE determines that the individual does not have an emergency medical condition, or the individual is not in active labor, the individual maybe informed of the risks and benefits of his/her treatment options. The individual may:
  • Acceptfurther treatment at the DED and financial liability (refer to facility specific collection policy for collection of patient pay balances); or
  • Refuse additionaltreatment. If treatment is refused, the hospital is to document such refusal and also document any plan for follow-up care provided to the individual (e.g., list of physicians, list of clinics, and list of health departments that offer care needed by the patient). This document must be maintained in the individual’s medical record.
IMPLEMENTATION:
1. Registration/Business Office personnel must educate all staff associates responsible for registering, billing and maintaining an individual’s records that are receiving services under EMTALA.
2. Education that includes specific EMTALA instruction regarding appropriate discussion about, and responses to, financial inquiries regarding services rendered in the DED must be created for and received by anyone who may be in a position to conduct such discussions with patients (e.g., registrars). Such individuals must complete the training before engaging in financial discussions.
3. The Registration supervisor should observe personnel throughout the employee’s evaluation period to ensure compliance with this policy. Deviations from this policy will be reported as part of the hospital’s performance improvement and the appropriate corrective action taken to ensure compliance.
4. Any signage regarding payment beyond that specified in the EMTALA – Signage Policy, LL.EM.004, must be approved by the facility’s Legal Operations Counsel.
The Facility Ethics and Compliance Committee is responsible for implementation of this policy within the facility.
REFERENCES:
Social Security Act, Section 1867, 42 U.S.C. 1395dd, Examination and Treatment for Emergency
Medical Conditions and Women in Labor (CCH)
Social Security Act, Section 1867, 42 U.S.C. 1395cc, Emergency Medical Treatment and Active
Labor Act
42 Federal Register 489.24, Special Responsibilities of Medicare Hospitals in Emergency Cases
Federal Register 489.53, Terms of Provider Agreements, Acceptance of Program Beneficiaries
EMTALA Medical Screening Policy, LL.EM.001
EMTALA Stabilization Policy, LL.EM.002
EMTALA Transfer Policy, LL.EM.003
EMTALA Signage Policy LL.EM.004
EMTALA Central Log Policy, LL.EM.005
EMTALA Duty to Accept Policy, LL.EM.006
EMTALA Provision of On-Call Coverage Policy, LL.EM.007

1/2005