Download - Kansas Hospital Association

EMTALA Update
Kansas Hospital Association
Wichita Airport Hilton
Executive Conference Center
Wichita, Kansas
March 5, 2009
Matthew C. Hesse, Esq.
Associate General Counsel
Via Christi Health System, Inc.
EMTALA
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Emergency
Medical
Treatment
Active
Labor
Act
Evolution of EMTALA
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1985–EMTALA enacted (42 U.S.C. §1395 dd)
1989–Statutory “enhancements”
1990–More statutory “enhancements”
1994–Interim final Regulations
1998–HCFA Interpretative Guidelines to Surveyors
1999–Special Advisory Bulletin (OIG/HCFA)
2000–Outpatient Prospective Payment System Regulations
2001–OPPS Q & A
2002–CMS Guidance Letter, Proposed Regulations
2003–Final Rules and Regulations
2004–Revised CMS Interpretive Guidelines
2005–EMTALA Technical Advisory Group
2008–Revised CMS Interpretive Guidelines
Penalties for Violation
of EMTALA
• Stakes are high for both hospitals and
physicians
Penalties for Violations
– Penalties for Hospitals:
 $50,000 civil monetary penalty (CMP) for each negligent
violation ($25,000 for a hospital with less than 100 beds);
 Civil liability to any individual who suffers harm as a direct
result of a hospital’s violation;
 Civil liability to any medical facility that suffers a financial loss
as a direct result of a hospital’s violation (transferee hospital
who receives an inappropriately transferred patient);
 Possible termination of hospital’s Medicare Conditions of
Participation Provider Agreement
Penalties for Violations
– Penalties for Physicians:
 $50,000 CMP for a physician who commits:
 A negligent violation (exclusion from Medicare for gross and flagrant
or repeated violations) including:
» Verifies transfer certification knowing or should have known that
risks outweigh the benefits of transfer;
» Misrepresents individual’s medical condition or other information,
including hospital’s obligations under EMTALA
» Failure to appear to stabilize a medical emergency within a
reasonable time and the ED physician orders transfer of the
patient because without services of the on-call specialty
physician, the benefits of transfer outweigh the risks of transfer;
Penalties
Office of Inspector General News
Office of Inspector General
Department of Health and Human Services
330 Independence Avenue, SW
Washington, DC 20201
Administrative Law Judge Upholds HHS-OIG’s $50,000 Civil
Monetary Penalty Against St. Joseph’s Medical Center
For Violating EMTALA
88-Year-Old Man Died in Emergency Room
Without Treatment
EMTALA Basics
• EMTALA requires Medicare participating
hospitals having a Dedicated Emergency
Department (ED) to:
– Provide appropriate medical screening examination
(MSE) to anyone who comes to an ED and requests
examination or treatment of a medical condition
– Provide necessary stabilizing treatment to an
individual with an EMC or an individual in labor
– Provide an appropriate transfer if either the individual
requests it or the hospital does not have the capability
or capacity to stabilize the EMC
EMTALA Definitions Important
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“Comes to Emergency Department”
“Dedicated Emergency Department”
“Emergency Medical Condition”
“Hospital”
“Hospital Property”
“Inpatient”
“Labor”
“Participating Hospital”
“To Stabilize”
“Transfer”
Medical Screening Examination
Requirement
• MSE is the process required to determine whether
an individual has an emergency medical condition
(EMC) or not.
• Triage ≠ MSE (triage determines order in which
patients are seen, not presence of EMC)
• CMS says MSE an ongoing process rather than an
isolated event
• Documentation is key in determining whether an
appropriate MSE was performed
Medical Screening Examination
Requirement (cont.)
• “Appropriate medical screening exam” is a screening to
determine the existence of an EMC which is the same or
similar to the screening provided to all patients presenting
to the ER complaining of the same condition or exhibiting
the same symptoms or condition (non-discriminatory)
• EMTALA governs non-uniform treatment, not incorrect
treatment
• EMTALA is not a malpractice law. Misdiagnosis is judged
in state courts under state negligence rules
Medical Screening Examination
Requirement (cont.)
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“Emergency Medical Condition” means:
1. A medical condition manifesting itself by acute
symptoms of sufficient severity (including severe
pain) such that the absence of immediate medical
attention could reasonable be expected to result in:
i.
Placing the health of the individual (or with respect to a
pregnant woman, the health of the woman or her unborn
child) in serious jeopardy,
ii. Serious impairment to bodily functions, or
iii. Serious dysfunction of any bodily organ or part; or
Medical Screening Examination
Requirement (cont.)
2. With respect to a pregnant woman who is having
contractions
i.
That there is inadequate time to effect a safe transfer to
another hospital before delivery, or
ii. That transfer may pose a threat to the health and safety of
the woman or unborn child
Medical Screening Examination
Requirement (cont.)
• Which hospitals must comply with EMTALA?
– Any Medicare participating hospital (Medicare
Provider Agreement)
– Includes a Critical Access Hospital (CAH)
Medical Screening Examination
Requirement (cont.)
• Critical Access Hospitals that operate Dedicated
Emergency Department must comply with EMTALA.
• If facility designated CAH meets certain criteria including:
– Located more than a 35 mile drive from any other hospital
– Maintains CoP, including requirement to make available 24 hour
emergency services 7 days per week
• In the revised SOM (2008), there are now separate D. Tag
numbers for regular hospitals (A), and for Critical Access
Hospitals (C)
Medical Screening Examination
Requirement (cont.)
• Deficiency Tags Used for Citing Violations
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A-2400;C-2400 Policies/procedures which address anti-dumping
A-2401;C-2401 Receiving hospitals must report inappropriate transfers
A-2402;C-2402 Posting signs
A-2403;C-2403 Maintain Transfer Records (5 years)
A-2404;C-2404 On-Call Physicians
A-2405;C-2405 Logs
A-2406;C-2406 Appropriate Medical Screening Examination
A-2407;C-2407 Stabilizing treatment
A-2408;C-2408 No delay in exam or treatment to inquire about payment
A-2409;C-2409 Appropriate transfer
A-2410;C-2410 Whistleblower Protection (retaliation)
A-2411;C-2411 Recipient Hospital’s responsibilities (nondiscrimination)
Medical Screening Examination
Requirement (cont.)
• Hospitals that do not have EDs are required
to have policies and procedures to assess
presenting emergencies, provide immediate
assistance and arrange transport to an
appropriate hospital. Such hospitals must
accept an appropriate transfer if they have
the capacity or capability that a transferring
hospital lacks.
Medical Screening Examination
Requirement (cont.)
• EMTALA protections apply to all persons (not
just Medicare patients) who come to the ED
that operates a dedicated emergency
department
• Under Born Alive Infants Protection Act of
2002, this includes every infant member of
the species homo sapiens who were born
alive at any stage of development
• Illegal immigrants are also covered by
EMTALA
Medical Screening Examination
Requirement (cont.)
• What does “comes to the Emergency Department”
mean?
– Patient presents to Dedicated Emergency Department
(DED) and requests care
– Patient is outside the DED but on hospital property within
250 yards of main building with an EMC
– Patient is in hospital-owned and operated ambulance for
EMC and treatment even if ambulance not on hospital
property; or
– Patient is in non-hospital owned ambulance on hospital
property for examination and treatment at DED
Medical Screening Examination
Requirement (cont.)
• Did patient request treatment?
– Verbal request by patient or by someone else on
behalf of the patient
– Individual presents to DED and a prudent lay person
observer would believe that the individual needs
treatment for perceived emergency condition
– Patient presents elsewhere on hospital campus and
prudent lay person observer would believe the
individual needs emergency care
Medical Screening Examination
Requirement (cont.)
• Does your hospital have a DED? Must meet one of the
following requirements:
– Licensed by the state as an ER/ED
– Held out to the public as a place that provides care for EMCs; or
– During the calendar year preceding at least 1/3 of all outpatient visits for
treatment of EMCs on an urgent, unscheduled basis
• May include labor and delivery department, psychiatric
unit, urgent care center or other departments meeting one
of three definitions
• May also include specialty hospital
Medical Screening Examination
Requirement (cont.)
• EMTALA does not apply to:
– Individuals who present to non-hospital-owned structures
within 250 yards
– Patients who come to the hospital for routine outpatient care
– Inpatients (CMS cautions that a patient must be admitted in
good faith for further necessary medical care admitted as
expected the patient will be admitted at least over night).
– Off-campus departments without a DED (however, such
departments must train staff and have appropriate protocols
for handling emergency cases or contact emergency
personnel at the main hospital campus, or call 911)
Medical Screening Examination
Requirement (cont.)
• Prisoners should receive an EMTALA screen
and stabilizing treatment if law enforcement
request clearance for incarceration or after
accident to determine if emergency exists
• EMTALA is not applicable if individual is
brought to ED by law enforcement to request
blood draw for BAT (drunk driving)
Medical Screening Examination
Requirement (cont.)
• Who can perform the medical screening
exam?
– Licensed physician
– Qualified Medical Personnel (QMP) as noted in
hospital bylaws or rules and within the scope of
practice and approved by the hospital
Medical Screening Examination
Requirement (cont.)
• A hospital may not delay a medical screening
examination or treatment to inquire about
individual’s method of payment or insurance
• Hospital may not seek authorization from a
patient’s insurance company until after the
MSE and stabilizing treatment
• A DED physician or extender may contact
individual’s physician regarding medical
history and needs as long as such consult
does not delay exam or treatment
Medical Screening Examination
Requirement (cont.)
• Hospitals may follow reasonable registration processes for
individuals where MSE or treatment is required, including
asking about insurance as long as the inquiry does not
delay screening or treatment
• Registration processes may not unduly discourage
individuals from remaining for further evaluation
• If patient inquires about financial liability, staff should
indicate regardless of patient’s ability to pay, the hospital
stands ready and willing to provide screening or
stabilization services
Medical Screening Examination
Requirement (cont.)
• Hospitals offering part-time emergency
services enjoy an exception from EMTALA
obligations at times when emergency
services are not available.
• Hospitals without DEDs must still comply
with EMTALA’s requirements if it has the
ability to treat patients with EMCs
Medical Screening Examination
Requirement (cont.)
• Effective October, 2007, CMS requires
Critical Access Hospitals and other hospitals
that do not have physicians on duty 24/7 to
provide the patient written notice of that fact
and what the hospital plan is to deal with
emergencies when a physician is not on the
premises
Medical Screening Examination
Requirement (cont.)
• A minor child can request an exam and/or
treatment for an EMC and the MSE should not be
delayed by waiting for parental consent. Under
EMTALA, a minor can be examined, treated and
even appropriately transferred to another hospital
without parental consent
• Patient “parking.” As soon as ambulance arrives
on hospital property, regardless of whether the
patient remains on the ambulance stretcher or
transferred to a hospital cart, EMTALA obligations
are triggered
Stabilizing Treatment Requirement
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Hospital’s duty to stabilize arises when it
detects an emergency medical condition
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If MSE detects EMC, three ways for
hospitals to discharge duty:
1. Provide treatment necessary to stabilize condition;
2. Admit the patient as an inpatient for further stabilizing
care; or
3. If unable to stabilize, transfer patient appropriately to
facility capable of stabilizing patient
Stabilizing Treatment
Requirement (cont.)
• Documentation of presence or absence of
EMC is very important
– Presence of EMC triggers all EMTALA requirements,
obligations, certifications, penalties and liabilities
– Absence of EMC releases physician, hospital, on-call
specialist from EMTALA requirements
– Recommend notation in chart: “no emergency medical
condition exists” (or “emergency medical condition is
stabilized”)
Stabilizing Treatment
Requirement (cont.)
• Any woman in active labor is considered
unstable under EMTALA, preventing
discharge or transfer, unless the transferring
hospital has absolutely no capability to
deliver the baby safely.
• Benefits of transfer must outweigh the risks
• Hospitals not capable of handling high risk
deliveries of high risk infants should have
written transfer agreements with facilities
with such capabilities.
Stabilizing Treatment
Requirement (cont.)
• Once a patient’s labor is determined to be false,
she is stable and EMTALA no longer applies
– As of August, 2006, CMS allows a nurse midwife or other
qualified medical practitioner (QMP) other than a physician
to make the false labor determination
 QMPs must be acting within the scope or practice as defined in
hospital medical staff bylaws and state law
– Hospital boards must approve the category and practitioners
allowed to perform MSE and stabilize (physician must certify
diagnosis of false labor by QMP)
Stabilizing Treatment
Requirement (cont.)
• Hospital is not liable for an EMTALA violation if
it had no actual knowledge that an EMC existed
– Hospital must demonstrate it provided appropriate MSE
– Hospital must show it provided patient with exam
comparable to one offered to any other patient presenting
with similar symptoms
– Tenth Circuit ruled that a hospital had no liability under
EMTALA because of an absence of actual knowledge of
an a EMC (Urban vs. King; Green vs. Reddy)
Stabilizing Treatment
Requirement (cont.)
• “To Stabilize” means with respect to an EMC, to
provide such medical treatment of the condition
necessary to assure within reasonable medical
probability, but no material deterioration of the
condition is likely to result from or occur during a
transfer of the individual from a facility or that, with
respect to an EMC, the woman has delivered the
child and placenta
• A patient can be in critical condition but still be
considered stabilized for EMTALA purposes
• Attending physician should be the person
completing transfer certificate setting forth risks and
benefits of transfer
Stabilizing Treatment
Requirement (cont.)
• A patient may refuse an MSE and stabilization
treatment. The hospital must:
– Offer examination and treatment
– Inform the patient (or surrogate) of risks and benefits of MSE
and stabilizing treatment; and
– Take reasonable steps to secure patient’s (or surrogate’s)
written informed consent to refuse examination and
treatment
– Burden of proof is on the hospital to prove that a patient
affirmatively revoked his or her request for examination and
treatment – DOCUMENT - DOCUMENT - DOCUMENT
Stabilizing Treatment
Requirement (cont.)
• A gatekeeper physician or managed care
organization has no authority to deny care.
They can refuse to pay for care, but they may
not deny it. Hospital must do MSE and, if
necessary, stabilizing treatment
• EMTALA obligations end for an Emergency
Department patient once the patient is
admitted to the hospital
Appropriate Transfers
• Physician certification of the risks/benefits of
transfer is a critical element of an
appropriate transfer and CMS specifies a
narrative particularized to the specific patient
involved in his or her circumstances
Transfer Requirements
• EMTALA governs transfer of patients from a Dedicated
Emergency Department
• A hospital can provide an appropriate transfer of an
unstabilized individual to another medical facility if and
only if:
1) The individual, after being informed of risks and hospital’s obligations,
requests a transfer
2) Physician signs certification that benefits of the transfer to another facility
outweigh the risks or QMP signs certification after a physician, in
consultation with that QMP, has made the determination that benefits of
transfer outweigh risks and physician countersigns certification in a
timely manner
Transfer Requirements (cont.)
3) Pertinent medical records regarding MSE or stabilizing
treatment must be sent to receiving hospital;
4) Obtain the consent of receiving hospital to accept
transfer;
5) Insure that transfer of unstabilized individual is effected
through qualified personnel and transportation
equipment, including use of medically appropriate life
support measures
Transfer Requirements (cont.)
• Only two instances in which an unstable
patient may be transferred:
– When hospital does not have the capacity or
capability to stabilize the patient, and the benefits to
be received by transfer to another hospital outweigh
the risks of transfer, and
– When the patient insists on transfer even after being
informed of the risks of transfer and the hospital’s
obligations under EMTALA.
Transfer Requirements (cont.)
• A hospital with specialized capabilities or
facilities (burn units, NICU, shock trauma
units, regional referral centers) may not
refuse to accept an appropriate transfer of an
individual who requires specialized
capabilities or facilities if the hospital has the
capacity to treat the individual. A refusal
under such circumstances would be
considered “reverse dumping”
Transfer Requirements (cont.)
• EMTALA requires an express written
certification for all unstabilized transfers
setting forth the risks and benefits analysis
and rationale for transfer
• Physician at the sending hospital has the
responsibility of determining appropriate
mode, equipment and attendants for transfer
– Transportation by an inadequately equipped
ambulance will violate EMTALA
Transfer Requirements (cont.)
• “Transfer” means the movement (including discharge) of an individual
outside of hospital’s facilities at the discretion of any person employed
by hospital, but does not include movement of an individual who:
– Has been declared dead, or
– Leaves the facility without permission of any person
• Movement of a patient from one area of the hospital to another
contiguous with the hospital campus is not a transfer
• If MSE reveals EMC and the individual is told to wait for treatment, but
individual leaves hospital, hospital did not dump patient, unless:
– Individual left ED based on a “suggestion by the hospital,” and/or
– The individuals condition was emergent, but hospital was operating beyond its
capacity and did not attempt to timely transfer the individual to another facility
Transfer Requirements (cont.)
• If a transfer is “appropriate,” the only valid
reason for a transferee hospital to refuse the
transfer is if it lacks the specialized
capabilities to treat the patient.
• Hospitals may not refuse a transfer because
of other issues such as alien status, payment
issues, or location.
Transfer Requirements (cont.)
• A receiving hospital is mandated to report
any transfers perceived to be in violation of
EMTALA
• Required to promptly report the incident to
CMS or state agency within 72 hours of the
occurrence. If recipient hospital fails to
report an improper transfer, the hospital may
be subject to termination of its provider
agreement.
Transfer Requirements (cont.)
• Specialty hospitals (participating in
Medicare) without dedicated Emergency
Departments must accept appropriate
transfer requests.
• EMTALA TAG Group recommended that such
hospitals are bound by the same
responsibility to accept transfers under
EMTALA as hospitals with DED.
On-Call Physician Issues
• Much contention, confusion and controversy
• Hospitals must maintain an on-call list of
physicians on its Medical Staff in a manner
that best meets the needs of its patients
receiving services required under EMTALA in
accordance with the resources available to
the hospital, including availability of on-call
physicians
On-Call Physician Issues (cont.)
• EMTALA mandates hospitals to provide and
confirm on-call schedules, but does not
require physicians to provide such services
• Physicians are required to participate in
EMTALA call as a condition of Medical Staff
for clinical privileges
On-Call Physician Issues (cont.)
• Medical Staff bylaws or policies/procedures
must define responsibility of on-call physicians
to respond, examine, and stabilize/treat patients
with EMCs
• Best practice = if particular services are
generally available to the public, they should be
available through on-call coverage of the ED
• Some physicians are dropping privileges
(decredentialing) or resigning privileges
altogether to avoid call responsibilities
On-Call Physician Issues (cont.)
• CMS allows hospitals “flexibility to comply with
EMTALA obligations by maintaining a level of call
coverage within its capability”
– CMS does not require specialists to be on-call at all times
– On-call physicians may continue to see patients in private
practice and perform elective surgery unless the physician is
reimbursed for being on-call at a Critical Access Hospital (42
C.F.R. 413.70)
– CMS allows valid excuses for not being able to respond to
call
– On-call physicians should have backup if s/he is in surgery
with own patients
On-Call Physician Issues (cont.)
– The amount of on-call coverage depends on hospital physician
resources available. Surveyors will consider all relevant factors:
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Number of physicians on staff
Number of physicians in a specialty
Other demands on physicians
Frequency with which patients require on-call physicians
Vacations, conferences, and days off
Hospital situations in which physician is not available or the on-call
physician is unable to respond
• CMS does not require certain levels of on-call coverage.
(No rule of 3 – no predetermined ratio of days per number of
physicians in certain specialty)
On-Call Physician Issues (cont.)
• When specialists services cannot be provided, the
hospital should have transfer policies or transfer
agreements with other hospitals that have the
capability to accommodate the needs of a patient
• Hospital may exempt members of Medical Staff
from EMTALA call (i.e., senior staff (age) or
number of years on staff) as long as exemption
does not affect patient care adversely. CMS will
carefully scrutinize overly generous exemptions
On-Call Physician Issues (cont.)
• Specialists may provide on-call coverage simultaneously
for more than one hospital as long as policies address
back-up coverage or transfers when on-call physician is
unavailable
• Physicians may not refuse to be on the call list, then
selectively see private patients in the hospital
• Non-physician practitioners may respond to a call from the
ED if the on-call physician determines it is appropriate
based on medical needs of the patient and capabilities of
hospital. (Board must determine if non-physicians can
provide stabilization services). However, if ED physician
disagrees with on-call physician, the on-call physician
must personally appear to stabilize
On-Call Physician Issues (cont.)
• Generally not appropriate to send a patient to an on-call
physician’s office for services. In determining whether a
hospital has appropriately moved a patient to the on-call
physician’s office, surveyors will consider the following:
– All persons with same medical condition are moved in such
circumstances regardless of ability to pay for treatment;
– There is a bona fide medical reason to move the patient. (Specialized
equipment in physician’s office); and
– Appropriate medical personnel accompany the patient
• Never make a transfer for the convenience of the specialist
– CMS will view this an endangering an unstable patient.
On-Call Physician Issues (cont.)
• Telemedicine – no EMTALA provision against
using telemedicine to examine patients. Remote
consultations are allowed, including at Critical
Access Hospitals
• CMS wants to see hospitals enforce their EMTALA
obligations
• For the Hospital Compensation Committee:
Improper structure of payments to on-call
specialists for on-call services may violate the
anti-kickback law. (See OIG Advisory Opinion,
September 2007)
On-Call Physician Issues (cont.)
• CMS has authorized voluntary community call plans
developed by 2 or more hospitals if the following elements
are met:
– Clear delineation of on-call coverage responsibilities;
– Applicable geographic area as specified;
– Signed by authorized representative of each participating hospital;
– Insure that EMS systems are aware of the arrangement;
– Patients arriving at hospital without designated call responsibilities are
still screened and stabilized;
– Annual reassessment of programs is performed by participating
hospitals.
Psychiatric Emergencies
• Psychiatric disturbances and symptoms of
substance abuse can cause an EMC
• CMS classifies suicidal and homicidal tendencies
as psychiatric emergencies
• Mental harm is more difficult to quantify than
physical harm
• If hospital lacks capabilities to perform mental
health exams, EMTALA does not apply
Psychiatric Emergencies (cont.)
• Psych patients present ED physician with
dual duty:
– MSE must be adequate to reveal emergent
psychiatric condition, and
– Physical medical emergency conditions (appropriate
lab and radiology testing)
• Medical record should indicate assessment
or suicide or homicide attempt or risk,
disorientation, or assaultive behavior that
indicates danger to self or others
Psychiatric Emergencies (cont.)
• ED physician must use good medical judgment in
attempting to stabilize psych EMC - no guidance
from CMS on this point
• Hospital must attempt to stabilize to the best of
hospital’s capability
• Patient may lack understanding or capacity to
communicate regarding exam, treatment or
transfer
• Consent is presumed in the event of an
emergency
Psychiatric Emergencies (cont.)
• A psychiatric patient is considered stable for
transfer when, by use of either medication or
physical restraints, the patient can be protected
from hurting himself or herself or others
• ED physicians should document in chart the
patient is stable for psychiatric transfer because
of
– Medical evaluation,
– Chemical restraints, or
– Physical restraints
Psychiatric Emergencies (cont.)
• Provider must affirmatively document that no
less restrictive measures are feasible under
the circumstances (CMS patient rights –
restrictions on use of restraints and
seclusion)
Psychiatric Emergencies (cont.)
• If, after MSE, hospital does not find an EMC, and hospital is
not aware of any EMC, the patient is stable for discharge
• For purposes of discharging a psychiatric patient, the
patient is considered to be stable when s/he is no longer
considered to be a threat to him or herself or to others
• Documentation of the MSE exam of psychiatric patient is
key
Psychiatric Emergencies (cont.)
• Examples of psychiatric and EMCs offered by CMS
(unofficial)
– Impending delirium tremens, detox, or seizures
– Expressions of suicidal or homicidal thoughts or gestures
– Intoxicated individuals
– Delusions, severe insomnia, or helplessness
– Self-mutilative or destructive behavior
– History of drug ingestion and patient with coma
– Inability to maintain nutrition with altered mental status
– Psychotic behavior
Technical Advisory Group
• Technical Advisory Group recommended
– Insertion of language “gravely disabled” or danger to
self or others, and who have an EMC, requiring
hospitals with specialized behavioral health capabilities
to accept such transfers when transferring hospital
does not have capability to provide stabilizing care;
– Clarify that chemical or physical restraints alone do not
stabilize psychiatric EMCs;
– More changes expected on handling Psychiatric EMCs
Enforcement
• CMS enforcement methodology:
– EMTALA enforcement is a complaint-driven process
– Even if complaint allegation is determined unfounded by
CMS, CMS instructs surveyors that they must still be
assured that the hospital’s policies and procedures,
physician certifications of transfer, etc. are in compliance
with law
– See attachment regarding EMTALA Complaint and
investigation
Helpful Sources
• Emergency Medical Treatment and Active
Labor Act (EMTALA)
 42 U.S.C. §1395dd
• EMTALA Regulations
 42 C.F.R. 489.24
• U.S. Department Health & Human Services
Medicare/Medicaid State Operations Manual
(SOM): Provider Certification Appendix V –
Interpretive Guidelines – Responsibilities of
Medicare Participating Hospitals in Emergency
Cases (Rev. 1, 05-21-04)
Helpful Sources (cont.)
• Revised State Operations Manual,
Interpretive Guidelines, Part II, (revised 3-212008)
• CMS.gov – Regulations and Guidance
• Final Report of the EMTALA Technical
Advisory Group (April, 2008) and
Recommendations of TAG, 1 through 55, and
Chart with Recommended Order of Priority
for CMS