PATIENT DUMPING AFTER 
COBRA

ASSESSING THE INCIDENCE AND THE PERSPECTIVES 
HEALTH CARE PROFESSIONALS

Richard P. Kusserow 
INSPECTOR GENERAL 
OAI-12-88-00830 
AUGUST 1988  ......... ............................................ ............. ................... . ......................... .................................................. 
........................................ .................................................... 
TABLE OF CONTENTS

Page 
EXECUTIVE SUMMARY 
INTRODUCTION....................................................................................................... 

BACKG ROU ND 
OBJ ECTIVES.............. 
........................................................................... 9 
METODOlOG  Y ............. 
.............................................................................. ........... 9 
FINDI NGS 
.................................... ...................................... j 2 
RECOMMENDATIONS 
APPENDIX 1 
State Intiatives in Patient Dumping 
Ara 
APPENDIX 2 
Calornia Anti-Dumping Legislation 
APPENDIX 3 
Agency Comments to the Drt 
Report  EXECUTIVE SUMMARY 
PURPOSE 
The purose of this 
study was to gain additional 
infonntion and insight into the issue of
patient dumping 1 1/2 year after the enactment of 
the Consolidated Omnibus Budget Recon
ciliation Act (COBRA) of 1985 which prohibited the practice. The inspection sought to deter
mine if objective measurment of the problem of 
patient dumping could be made using
existing reord and if perspectives of health care professionals identified vulnerabilties in the
urnt 
process of 
identiyig and reportng 
alleged cases. 
The overa objectives of this inspection were to detennne: 
if records maintaned by hospitals reflected information 
needed to assess the actual
incidence of patient dumping; 
reportng practices and procedures in place at hospitas for 
referrng possible cass and
complaits to the proper authorities; and 
the extent to which public hospitas continue to perceive patient dumping as a problem 
and their estimates of the 
fruency of patient dumping at their facilty. 
BACKGROUND 
The COBRA included provisions that 
requir all Medcar-p3rcipatig 
hospitas with emer
gency deparents to provide necessar medcal examations and tratmnts to 
dividuals with emergency medical conditions and women in active labor. After thset apbatiliiezn tin is  
stabiliz 
the hospita may provide for appropriate 
also alowed for penalties if a hospita or provider vitorlasfteesr  to another facilty. The COBRA
these antidumping provisions. In
adtion to COBRA, the Hill-BUrn Act 
of the Public Health Servce Act and varous 
laws alo outle  State
the respnsibilties of hospitas for the car of the indigent 
Recent arcles published in professional 
jourals, as well as newspaper accounts of patient
dumping, suggest that the problem may continue to occur despite 
Fedra and 
prevent it In July 1987, the Hum Resources and Intergovernenta  State effort to

Relations Subcommt
tee of the U.S. House of Representatives held an oversight 
hearg 
ing. Testiny  focusing on patient dump
focused on medcal problems which have resulted 
frm 
alleged cass
patient dumping, economic causes for patient dumping, and the Federa role 
in preventig and 
investigatig such cases.  METHODOLOGY 
Emergency room (ER) and other hospita records for the month of October 1987 for all 
patients trsferrd to the ER were subpoenaed frm 25 hospitas in 25 standad metropolita 
areas  (SMAs)  radomly selected with probabilty porportonate to size. The OIG 
conducted telephone interviews with  staf also
adistrators and health care practitioners in 88 
radom
ly selected public hospitas which had 100 or 
more beds and were located in or near an SMA 
to obtan their perspectives on 
the natue and incidence of cases of patient dumping. 
MAJOR FINDINGS 
Curnt reord 
keeping by hospitas makes objective measurment 
of the problem
dificult The hospitas in our record sample of 25 could not 
trsferr  uniformy or consistently
identiy al patients  to their ER frm other ERs. Even if 
can be identified information contained in the record is  transferrd patients
limited. 
Due to the diculty in objectively measurg 
the incidence of dumping, confusion
exists as to the actual extent of the problem. Perceptions 
var widely among health car
pratitioner. For example, the hospitas in our 
admnistrtor and practitioner samle
88 could offer only anecdota estimates of dumping prevalence and these 
diere
considerably. Of those 
hospita in our sample willng to 
estiate the rate of dumping,
25 (32 percent) 
report no problem at all with dumping, while 35 (45 percent) believe
they curntly experience COBRA dumping at least once a month. 
A signcant number of hospitas (39 percent) in our 
adnistrtor and practitioner
sample of 88 did not have 
procedurs or 
reportg mechanisms to effectively deal with
patient dumping when it 
occur. Hospitas seem unawar of mechanisms for the proper
reportng of dumping incidents. When they ar awar of such mechanisms, they
reluctat to use them.

Prctices 
persist, such as the diversion of patients en route 
trsprttion;  durng ambulance
the referr of patients to another facilty without makng a 
reord of
their reuest for tratmnt at the primar facilty; or 
the trsfer of patients citig
inabilty to trat the patient properly, when the facilty in fact 
appear equipped to car
for the patient These pratices, 
at miimum, subven 
the intent of COBRA even though
ditly 
they may not 
violate its provisions. 
In the absence of statistically reliable information on this problem, the 
Deparnt of
Health and Human Servces (HS) must rely heavily on hospitas to file complaints
unde Hi-
Buron and COBRA. Given the lack of 
reord keeping and reponing by
hospitas, as documented in ths report, the abilty of IfS 
to monitor and overse this
prblem is jeoparzed  RECOMMENDATIONS 
Reportg of suspected cases of patient dumping should be made a condition of 
parcipation in the Medcare progrm or par of a hospita' 
s provider agrement in order
to incrase reponing. This 
recommendation was communicated to the Health Care 
Financing Admistrtion (HCFA) in an early alert on this subject. The HCFA has
accepted this recommendation and included it as a 
requirment in the IfS 
regulations
on dumping issued in June 1988. 
In view of the reliance on 
refeITals from patients and hospitas to enforce 
HCFA and the Offce for Civil Rights (OCR) should use existing authorityth teoi rr aequuthiroerity,
and ensur that hospitas post 
notices such as the ones 
curntly posted in California
hospitas and those provide by OCR to Hill-Buron facilties. All
Medicar-
parcipating hospitas and all Hill-BUron facilties should post 
their ERs which (1) inform patients of their rights under COBRA and Hil-notices in
Burton and 
(2) indicate a local or toll-
free number to call with complaints. 
The COBRA regulations should 
requir that 
all ER record clearly identify all
trsferrd 
patients to and frm 
other ERs. Al patients should be asked 
an ER if they have sought  upon arval at
tratment elsewhere. 
Dirt outrach to professional associations should be pursued by the 
progrm aras
respnsible for COBRA 
and Hill-BUron compliance with increased vigor in order to 
incrase awarness and stimulate proper reportg by health car professionals. 
The HCFA should move to 
clarfy the defInition of what constitutes "stabilzation 
emergent condition, " and
" as the American College of Emergency Physicians (ACEP) has 
done, in the COBRA regulations or 
though propose legislation 
in order to clary
physicias' reponsibilties under COBRA. To the extent 
possible, coordiation should
tae place with OCR to assur that the Deparent 
uses a common defmition of terms
when enforcg its 
authority in this ara. 
AGENCY COMMENTS 
Comments to the drt 
report were received 
frm HCFA, OCR and the Public Health Service.
Although ther was genera agrment with 
the report s findigs and 
expresse reseation concerng  recommendations, HCFA
our recommendations for 
ther defition of crtical terms. Our  incrasedn reeceor d keeping and fu

findings indicate that action is 
reommendig that HCFA tae these steps to strengten the Deparent  and we ar agai
the COBRA provisions. Agency comments  s abilty to enforce
ar contaed in 
appendi 3.  INTRODUCTION 
BACKGROUND 
The pratice of patient dumping--
that is, the trsfer of unstable patients or refusal to render
emergency tratment to 
patients based on grounds unrlated to need or 
the hospital' s ability to
provide services--has become a serious concern in recent years. Some 
expens assert that, due
to incrasing fmancial pressures to maitain profitability 
and reduce costs and the increasing
number of uninsurd or 
underisurd Americans requesting access to health car
trsferrg  , hospitas are
tuing away or  large numbers of indigent and 
uninsurd people from their
emergency roms without appropriate medical evaluation.  Estites of 
the national
fruency of patients transferr for economic reasons have been placed as high as 250,
2 although such estimates 
cases anually, ar 
statitically unsur. 
In some cases, the denial of care results in 
die consequences for the individual. Concerned
members of the medical community, famly members and 
frends, and patient 
advocates from
acoss the countr have reported deaths and serious ilness resulting 
frm 
denial of emergency
tratment. One Tennessee woma, for example, related the story of her diabetic neighbor, a
young carenter, who was "physically removed" from an emergency room (ER) due to an in
abilty to pay for services and strded in the hospita' s parkig lot after arving at the ER in
an amsbutlian ce on his doctor s orders. He died the following day at home.3 Such practices 
have  considerable debate in the medcal community concerning the proper 
tratment of
and respnsibilty towar indigent or other undesirable patients. In adtion
governnts  ma  , Fedra and State
have both  effort to provide protetion for persons 
who sek emergency
room car 
regardless of their abilty to pay.

Federal Efforts 
The fIrst Fedra effort in this 
ara was the community servces provisions included in the Hi-
Buron Act of the Public 
Health Servce Act, 42 U.  C. 216, 300-4 and 3001(6) 
and XV in 1979. The reguations implementing the  (titles VI
community servce assurces 
al hospitas that reeived Fedra  apply to
assistace under the Hil-BUrn Act which was enacted into
law in 1946. The act authori 
the appropriation of funds, chaneled thugh 
the States, for
the constrction or modrntion of 
hospitas and other health facilties. 
The community ser
vice assurces prohibit Hi-
BUron hospitas 
frm denyig emergency servces to anyone
who resides in the hospita' 
s servce ara (title VI of the Public Health Service Act). 
Hospitas
that have reived Fedra 
assistace under title XV ar also requird to provide emergency
servces to peons who wor in the hos ita' s service ara. Unlie the "fr car obligations 
The'ifp  tie 
of:H a1thanQHtimaif Semce-s(HS),OfceforCivilRightS.
spn' sible:for:enfOIing thl:(:oJ'rnw,i  oocc:assurcescof the Hi.;BUron  (OCR) iSS
Acm However,
some dificulties have 
ben documented concerning OCR's effort in this ara. For example,  OCR has been crticized for not 
rovidi 
their obligations. 
The second Federa effort to 
assur emergency services for all those that seek such care was
enacted in Apri 1986 
(effective August 1986) in the Consolidated Omnibus Budget Recon
cilation Act (COBRA) of 
1985, which amends title xvm of the Social Securty Act. The
COBRA  parcipatig 
reuirs al Medicare  hospitas with emergency deparents to: 
provide for an appropriate medcal  (1)
screning for patients 
presentig themselves for tratment
to determne if an emergency medcal condition exists or 
the person is in active labor; and (2)
if such an emergency condition or active labor exists, provide 
tratment with the hospita'
capacity or 
trsfer the patient to another 
facilty for tratmnt under the followig restrctions: 
The patient must be stabilzed, unless a cenification has been signed by the 
physician attstig that the benefits of a 
trsfer outweigh its risks. 
The reeiving hospital 
must have the necessar space and personnel to effectively 
trat the patient

The reeiving hospita must be notified of the trnsfer, and must accept the trsfer. 
Medical record must accompany the patient 
The trsfer must be effected with proper 
trsportation equipment and qualfied 
personnel. 
The COBRA 
alo provides for termation or suspension of Medicar provider agrements if
violations of the  wiy, 
proviion ar knowingly and  or negligently violated and the imsi
moneta 
tion of civi  penalties agaist the hospita and/or respnsible physici(s) wher 
proviion is knowigly violate In adtion,  the
reeivig 
individual and  hospitas may bring a
dciavig aectsi on agaist a referrg hospita which violates the provisions of COBRA, and obta
for peonal har or fiancial loss. 
Although simar to 
reuiments include under the Hil-BUrn 
Act, COBRA broadns the
rage of applicable providers, as well as the services requi 
to be rendere in the emergency
lroiotme.  As note above, remedes available under Hi-Buron to engender compliance
to volunta measurs 
and possible referr of 
the hospita to the U. S. Deparent of
Justice, which can sue for 
specic performance. The COBRA
, conversely, provides for more
spifc 
enforcement and remedes for violators, including the imposition of 
civi money
penalties (CMPs).  Th IfS 
components are involved in compliance and enforcement activities of the Hill-
Bur-
ton and COBRA provisions: the OCR, OIG, and Health Cae Financing 
Admnistrtion
(HCFA). Overlap does exist between agency authority generated in 
par by the inherent over
lap of the statutes. For example, if a hospital that dumps a patient has obligations under 
Hil-
BUron and parcipates in the Medicare progr, all thre agencies would become involved
with investigating the complaint. 
Other Efforts 
In adtion to the above-referenced Federa efforts, at least 23 States have enacted statutes or
adistrtive 
regulations to addrss provision of 
sur  emergency car for the indigent or unin
As the table in appendi 1 indicates, State initiatives in ths ara var 
broady in terms
of defming an emergency, coverage of pregnant women
, and provision of remedy for viola
tions. Many do not 
conta remedes at all for violations. However, some States have in
stituted requirments that ar strcter than those imposed 
at the Federal level. 
The strctest State antidumping 
statutes are found in Calforn New York, and Texas. 5
Calornia s is parcularly extensive.
and merits some detaed discussion here. Under Calor
nia law, patients must sign "informd consent" form which outline "the reasons for 
refusal to provide emergency services and  trsfer or
car and of the person s right to emergency services
and car prior to trsfer or discharge without regar to ability to pay. ,,6 The State of Caor
nia also reuies that notices be posted in all emergency roms informg 
patients of their
rights to emergency 
car. (Curntly, OCR provides such notices to its Hill-
Buron facilties,
but HCFA does not requi postigs in al Medicar-parcipatig facilties. trs
fers must be filed with the State. Receiving  ) Records of 
hospita personnel must report violations. Finally,
the law reuis that "as a condition of licensure, each hospita 
shal adopt, in consultation
with the medical  trsfer 
sta, policies and  protocols consistent with this 
tions adopted hereunder. " 7 A copy of the bil adopted in September 1987 aarncdl e and regula
enacte on
Januar 1, 1988 by the State of Calfornia is contaed in appendi 
Other States, whie not matching Calfornia in scope of coverage, have also enacted 
laws with
provisions of interest. For example, the State of Michigan 
s antidumping statute includes a
prohibition agaist ambulance diversion: "An ambulance operation, or a 
limite advanced or
an advanced mobile emergency 
car servce shal provide emergency car consistent with its 
license to al patients without prior inquir into abilty to payor soure of paymnt " 8 Mis-
Uta 
sour and  include psychological or menta emergencies in their coverage of emergency 
servces to whih the indigent will have access. Uta 
defines emergency medcal services to
mean "seces use to respond to perceived individual needs for 
immedate medcal car in
order to prevent loss of life or 
aggrvation of physiological or 
psychological illness or injur. ,, 
Wisconsin' s law, lie that of Massachusetts, specifically prohibits delays in 
tratment: "
hospita providig 
crt  emergency services may delay emergency tratment to a  injur 
son unti  checks, fmancial information forms or promissory notes havesi ck or  per
ben initiate
complete or signed if, in the opinion of one of the 
followig, who is an employee, agent or
sta member of the hospita, the delay is likely to 
cause incrasd medcal complications, per manent disabilty or death: (a) a 
physician, registered nurse or emergency medical technician
advanced (paramc);  trned 
(b) a  practical nurse under the specific diction of a physician
or registered nurse; or (c) a physician 
s assistant or any other person under the specific 
diec
tion of a physician. ,, 10 The Wisconsin law also requirs 
that hospitas establish wrtten 
car  proe
dures to  out this diective. 
Furer, each hospita must create a plan for referrs 
when
the hospita cannot provide 
car and the S tate wil identify the ER capabilties of each hospita
and update the list annually. 
The Texas antidumping law has been used as a model for 
severa States and for the Federa
COBRA legislation. It prohibits the refusal to provide diagnosis or 
warts  car if the diagnosis so
to any person based on age, sex, physical condition or economic status. The Texas 
law defmes emergency servces to mean "
services that 
ar usualy and customarly available at
the respetive hospita and 
that must be provided 
imediately to susta a person 
prevent serious  s lie, to
perment disfigument or loss or impaient of the function of a boly
member or organ, or to provide for the 
car of a woma in active labor if the hospital is so
equipped and, if the hospita is not so equipped, to provide necessar treatment to 
alow the
woman to trvel to a more appropriate facilty without undue risk of a serious har. 
" 11 
In adtion
, at least five States--
Florida Massachusetts, New Ie  ey, New York and South
Caolina--have established "indigent pools" which fInance health car for the poor and help to
relieve the fiancial burden impose 
on hospitals carg for such patients. 
agr 
Medical expert  that the need to provide an appropriate medical evaluation of the patient 
prior to trsfer is crcial if the patient s well-being is to be ensured If the patient s mecal
condition necessitates 
tratment prior to effectig the trsfer, appropriate servces must be
provided Severa professional medical organizations have adopted policies which underscore 
the need of the medical professional to provide such 
tion (AM) has adopted a position  car. 12 The American Medcal Associa
mor  neei ndicatig that al physicians and health car facilties have
obligation to provide  medcal car to 
al those who seek it regardless of their
abilty to pay. Furermore, the AM 
supports the position that an interfacilty 
onl ifit is done/or the patients best  trsfer should 
tae place  Also, the 
only if both the  interest.  trsfer should tae place
transfeng and 
reommende that interhospita trreseifveirn ga gphrymsiecniatsn  bceon sent to the trsfer; and, the
worked out at the local level. 
The Amercan College of Emegency Physicians
TAhMe A' sC, bEu ta, luson perv itdhees A mMor,  sdpectiafieeds  tinhafot nthnet ipo'a n(tiA ernCetg Esah) ropnuoglldi  cbye  ssttaatebmielnit  pisr isoirm tloa rt rtsof tehre.
appropriate trsfer, and stabilz
ing steps which should be 
taen prior to 
aiay  trsfer. 13 These steps include: establishing an ade
quate 
stag  and ventiation, controllng bleeding, splinting factus, tang vita 
signs, and
intrvenous medcation or initiatig 
bloo replacement. 
The ACEP has also provide a detaed descrption 
of what constitutes a medcal emergency:
( 1) any condition resultig in admssion of 
the, patient to a hospita or nuring home within
24 hour; (2) evaluation or 
repai of acute (less than 72 hour) truma; (3) relief of acute or
severe pai; (4) investigation or relief of acute infection; (5) protection of public health: (6)  obstrtical crisis and/or labor; (7) hemorrhage or theat of hemorrhage; (8) shock or impend
ing shock; (9) investigation and management or 
suspecte abuse or neglect of a person which
if not interrpte could result in temporar or permanent physical or psychological har; 
(10)
congenita defects or abnormalties in a newborn infant, 
best managed by prompt intervention;
(11) decomposition or theat of decomposition of vita functions, such as sensorium, 
respira
tion, circulation, excretion, mobilty, or sensory organs; (12) 
maagement of a patient
suspecte to be suffering from a mental illness and posing an apparnt dager to the safety of
himself, herself, or others; and (13) any sudden and/or serious symptom which might indicate 
a condition which constitutes a that 
to the patient s physical or psychological well-
being re
quirng imedate medcal attention to prevent possible deterioration, 
" 14 
disabilty or death.
Both the American Hospita Association (AH) and the Joint Commssion on Accredtation 
Health Car Organizations (JCAHtO) srupposrt thef posietion thart pat.ient s should not be 
trsferr aritry. Both AH and JCAHO indicate the deision to 
trsfer should
medcaly permssible 
(the patient is stable), and the 
trsfer should be made only afer the
receiving hospita consents to the 
Prvious studies of patient dumping.have been conducted by medcal  Hi
and health expert. 
melstein and Woolhandler15 
conducted a study in a large urban ara, examing trsfers
frm private to public hospita emergency 
roms. The study found that trsfer seems to "tr
age patients into the public setor bas on fmancial and socal factors. 
note  " The authors also
that of the 458 conseutive patient 
trsfers studied 33 of the patients reeived substa
dad car either beause of potential complications that could arse durg trsit, 
or beause
tratment was delayed They 
adtionally found an absence of mecal reasons for the trsfer
to the public hospita emergency rom suggestig the reason for 
trsfer was economic. 
Schiff and Ansell 16 conducted a similar study 
of patient trsfers to a public genera hospita
in a lare uran ara. The researhers examned reasons for patient 
patient was adtted to the intensive car unit, length of stay, and outtrcsofmeres, ,a mwhoentgh eorth tehr efac
tors. The researherst fhou nd that the reason for trsfer in 87 percent of the cases was lack of
insurce. Seventy- adttd 
percent of the patients were  to the surgical servce, and 27 
adtted 
percent  to the medcal servce. In adtion, of the char the researhers were able to
review, 24 percent were classifed as being in an unstable condition upon arval
trs-
, and the 
fer proess resulte in an 
average delay of tratment of 5. 1 hour. 
The authors estite that durg 1983, nonrimburable costs shifted to the public hospita
frm private hospita for the car of trsferrd patients totaed $24.1 milion dollar, or 12
percent of the hospita' s opeting budget This cost estimate, the authors note, represents
costs attbutable only to those patients trsferr and adtted to the surgical service or
mecal 
servce and not other 
trsferr  aras such as obstetrcs. The estimate alo does not include
patients  that were not adtted The authors state: "If our patients 
ar repre
sentative of medcal and surgical emergency-
deparent trsfers in 
other aras of the
countr, extrpolation to a 
national level suggests an annual cost shift of hundr 
of milions
of dollar from the 
" 17 
private to the public sector.  In July of 1987, the Human 
Resoures and Intergovernmenta Relations Subcommttee of the 
S. House of Representatives held an oversight 
hearng focusing on patient dumping. Tes
timony was hear from victis of 
patient dumping, patient advocacy groups, and repre
sentatives frm HHS. Testimony focused on medical problems which have resulted from 
patient dumping, economic causes of patient dumping, and the Federal role in preventing such 
cases. 
The subcommttee was parcularly interested in HHS' effort to implement the COBRA
provisions and enforcement efforts of existing laws prohibiting patient dumping. The Ad
miistrtor of 
HCFA testied that HCFA had sent interim operatig instrctions to 
their
regional offces (ROs) 
detaig what actions the regions should 
tae upon receipt of a patient
dumping complait. Also, it was noted that the regulations 
formaly implementing the
COBRA provisions (the COBRA provisions were self-
implementig) would be 
published
soon. A Notice of Prposed Rulemag 
(NPRM) was eventualy published in June 1988 con
drt 
taning  regulations. 
In Mach 1988, a report descbing the patient dumping problem as pervasive and 
IfS'  crtical of
actions to date in this 
ara was. published by the House Commttee on Government 
Oprations. 
OBJECTIVES 
The purose of this study was to gain 
adtional informtion and insight into the issue of
patient dumping 1 1/2 year after the enactment of the Comprehensive 
Omibus Budget
Reconcilation Act of 1985, 
which prohibited the practice. The inspection sought to detennne
if objective measurment of the problem of 
patient dumping could be mad 
record and if perspectives of health car professionals identified vulnerabiltuiseisn gin e txhies tcinugrnt
process of identifyng and reportng 
aleged cases. 
The overa objectives of this inspction were to detennne: 
reor 
mataed 
if 
by hospitas reflected information 
neede to assess the actual
incidence of patient dumping; 
reportg pratices 
and procedurs in place at hospitas for referrng possible 
cass 
and complaits to the 
proper authorities; and 
the extent to which public hospitas continue to perceive patient dumping as a 
problem, and their estiates of the frquency of patient dumping at their facilty.  METHODOLOGY 
Records Review 
In order to obtai objective information and attempt to statisticaly determe 
the prevalence
of patient dumping under COBRA, OIG subpoenaed emergency room records for a 
radomly
selected month (October 1987) from 25 large (300 beds or more) public and nonprofit hospi
tas in 25 SMAs radomly selected with probabilty proportonate to size. The subpoenas re
quested (1) any and  rom 
al emergency  logs or other ER records for the month of October
1987, which indicate those patients who were 
trsferrd from other hospitas to the ER for 
tratment; and (2) any record indicating the payment status (Medicar, Medcaid, commrcial
none or other) for each of the patients identied as having ben transferred frm another hospi
ta to the ER for tratment durg the month of October 1987. 
The purose of this effort was to obta information regarding the hospita's abilty to identiy 
patients at risk  (i. e.,  patients trsferred frm other hospitas with a payment status of
Medcaid or none) and to then  trsferrg
reuest medical record for those patients from the 
and reeiving hospitas. Those reords would then be reviewed by a physician panel to deter
mie 
the stabilty or instabilty of the patient upon trsfer. 
Penpectives of Health Care Professionals 
In order to obta hospita perspectives on this subject, OIG 
sureyed adnistrtors and pra
titioner in 88 hospitas concerng pratices 
and experiences in connection with patient dump
ing. The hospitas were selecte radomly frm the univers of 581 Medcar-parcipatig
public hospitas contaning at least  stada 
One hundrd hospitas were  100 beds locate near  metropolita aras  (SMAs).
selected. Of those 100, 4 declined to respond to our 
surey; 5 did
not offer emergency servces and were therefore 
drpped from the sample; 2 could not be
reached and 1 was a for-profit hospita erroneously include in the sample. Consequently, 88
hospitas comprised our study sample. Fifeen of these hospitas ar locate in the Norteast 
(HCFA regions 1, 2, and 3); 26 ar in the South (HCFA region 4); 28 ar in the Midwest 
(HCFA regions 5 and 6); and 19 ar in the West and Southwest (HCFA regions 7, 8, 9, and 10). 
Inteews 
were conducte by telephone by OIG sta in 
Dalas, Texas; Baltimore, Maland;"
and Washigtn, D.C. Intial contat cals were mad to the hospita adstrtor, who was
inored of  dit 
the reasn for our cal and asked to designate someone to whom we could 
questions. In 11 ptehrce nt of the cases, the adnistrtor indicated that he/she would like to
respnd. Th-
peent designated another member of the hospita adnistrtion 
(As
sistat Admstrtor Admstrtor 
for Financial Servces, etc.) to respnd; 47 
percent desig
nate nanu erm.e rgency rom Medcal Dirctor; and 9 percent designated an emergency rom
head  In most cass, follow-up cals were 
adtrtor  made to the designated respondent 
afer the
had the opportnity to inform the designated contact to expect our call.  The intervew took approximately 20-
25 minutes and concentrted on the following aras: 
existence of proedurs in. ER to deal with cases of patient dumping; 
existence of 
trsfer agreements between responding and neighboring hospitals
outlining procedurs for the appropriate transfer of patients; 
the OCCWTnce of instaces of COBRA violations (Le., 
emergent or active labor
patients transferrd to the respondent s hospital who were not provide medcal
screning at the sending hospita; who were transferrd without a medcal 
cenification that benefits outweigh risks or the patient requesting the trsfer; 
who 
trnsferr 
were  without advance notice by the sending hospita; who arved
without medical record; or who arved 
without proper trnsportation or medcal 
equipment); 
rate of COBRA dumping experienced; and 
experience with ambulance diversions.  FINDINGS 
Cun-ent record keeping practies by hospitals make objective measurement of the probkm
of patent dumping diffcult. 
For example, the hospitls  could
not uniformly or consistently identify all patents  in our record sample of  25 
transfen-ed to the emergency room. 
Severa hospitas could not identify 
transfeITed patients at all without a case by cas review of
hthoes prietacso rdde.f iSnoem tres hfeosrpsi ttaols i cnacnlu odne lrye fiedIeTnatlisy f trhmos ep rtihvaatt ewe rpe htrysfseiITceid ans,  and  admtted. Some
nuring homes, or other
health car facilties--not just other hospitas. Insurce infonntion was not always obtaied
or if obtaed confirmed, parcularly for nonadmtted 
patients. 
For example, one Chicago hospita responded to our subpoena that "
the information which is
curntly collected on our (ER adssion) logs does not include patients 
trsferrd from
other institutions. The only way to obtain that information would be 
a retreval of 2801 (in
dividual) medcal record for the month of October 1987. " One Connecticut hospita worker 
trsferr 
stated that "patients  and then discharged ar lost frm our system." The ER logs
we reeived did not tyically conta' a column for referr or trsfers, or even for payment
soure. Payment sour e inormation on the ER records themselves was oftn blan or did not
refer to a policy number, thereby bringing into question the actual existence of the policy 
cite
by the patient. 
mata 
tNaoende  of the hospita in our sample  trsfer log of any kid, such as the one ma
at Cook County Hospita and use by Schif and Ansell in their stUdy of trsfers
reeived at that facty. 
As a result of this inabilty by hospitas to identify trsferr 
patients, the abilty of OIG,
HCFA, or OCR to conduct efficient compliance reviews may be jeopardi Bas 
on this
rmding, we reportd the results of our record review to the regional dictors of OCR and
HCFA and inormng them of the  the reviews conducted in hospitas in
spific fidigs of 
their regions. We noted among other 
things, that improved record keeping is necessar in
ordr to ensur 
the abilty of the Deparent to conduct effcient compliance reviews and that
those reviews might have to consist of a system-
patt  wide approach in order to fully understad
the  of refeITs and trsfers among hospitas in a given 
geogrphic ara. 
da 
A prospectiv  colkction method (such as that used by 
Schif and AnseQ) may be the
only way to accurately count and identify transfen-ed 
patents at 
selected fadlities. 
We wer unable, based on the inormtion 
provided to us by the hospitas, to identiy accurte
trsferr 
ly the unvers of patients  to those hospita frm other hospitas' emergency
roms. Consequently, we did not underte the seond par of our reord review, which was
ttoi in volve the review of medcal 
reord by a physician panel. Therefore we canot at this
make any judgment concernng the extent of a dumping problem at 
unvere of  Bas  these facilties, or the
hospitas at lare.  on our experience, it appear that considerable time and  resoures would be requir to obtan this information on a national 
level. To our knowledge,
no one has yet underten 
such an effort 
Even if transfen-ed patnts can be identified, infonnaton contained 
in the record is limited. 
Many of the ER record sent to us do not indicate if prior approval to 
trsfer the patient was
obtaned, or if medical record were sent 
with the patient, and it is not clear if records frm 
trsferrng facilty  the
ti  will indicate these facts or not. Addtionally, this approach wil not iden
those patients who were 
tued away at a private hospita without medcal scning 
and
told to drve themselves to the 
public hospita's ER, or patients diverted en route (both vul
nerabilties 
identied by practitioners in our telephone interviews and 
discusse later in this
report). 
Due to the diffculty in 
objectively measuring the incidence of dumping, confusion exists as
to the actual extent of the problem. 
Perceptins var widely among practitioners as to the
extent of dumping at their 
facilites. 
Seventy-eight of the 88 respondents in our telephone sample of 
wig  adnistrtors and pra

titioner were  estite 
to  the amount of dumping at their facilty. 
Responses vared
widely. For example, 25 (32 percent) of these hospitas 
report no problem at al with dump
ing. However, 35 (45 percent) report they curntly experience reeiving trsfers in 
stada  viola
tion of COBRA  at least once a month. Ten hospita (13 percent) report
experiencing five or more cass in violation of COBRA a month. Some of those 
hospitas
reportg problems cited specifc cass. 
A Texas hospita pratitioner descrbe two: " 
woma about to have a baby was sent acss 
land, then by ferr, to us from a nonprfit hospi
tal. She left there six 
centieters diated and had the baby praticaly at our doorstep. (In
another cas), an older male went to his local hospita for a hear problem, medcation was not 
provide and was told to drve to (us). He anved with acute myocaral infartion. 
Twenty-one of the 88 hospitas in our sample (24 percent) 
report reeiving emergent or ac
tive labor trsfers frm ara hospitas who had not been 
medcaly scrned 
before trsfer.
Twenty-five (28 percent) reported trsfers anvig 
without mecal certcation or 
at the
patient s reuest Twenty-six (29 percent) reported trsfers arvig 
without mecal record;
23 (26 percent) report patients arving without proper trsprttion or medical equipment.
By far the most 
report prblem, identied by 50 hospitas (57 percent), was the lack of ad
vance notice by the sendig hospita. 
For our sample the mean number of dumps per month reported was 3.
9. However, as indi
cated above, ther was wide vartion in the responses, ragig frm zero (report by 25
the hospitas) to as much as 105 (reponed by one hospita).  veri 
We did not  these estimates.  Many hospitals do not have procedures or reporting mechanisms to effectively deal with in
cidents of patent dumping when they occur. 
Many hospita (39 
percent) do not have proedures that addess proper handling of inap
propriate trsfers received in the emergency room. Of those saying that they do have proce
durs, 33 percent state that they ar not wrtten. 
Overal, 25 (28 percent) of the hospitals indicated that they do not or would not report 
insta
ces of patient dumping. Of those indicating they would report 
such instaces, 35 (57 percent)
indicate their own hospita adistration as the highest level to which they would report. 
Only 11 percent indicated they would report to the State 
surey agency, the contact point en
courged by HCFA. 
th 
Twenty- of the 35 hospitas which indicated that the highest level of reportng was their
own hospita admstrtion also reported problems with dumping. Follow-up calls were 
mad to these 23 hospita adnistrtors to determe if they reported cases outside of the
hospita once alerted by their ER sta of a possible violation. Only the routinely fie com
plaits with State or Federa authorities. 
Hospital seem unaware of mechanisms for proper reportng of dumping incidents. When
they are aware of such mechanisms, they are reluctant to use them. 
We usualy just cal and fuss at them (the sendig hospita) when inappropriate trans
fers ar mad. Other than that, no reportg is done. I'm just not sur who to go to. "
(Albam hospita) 
'We would handle it between hospitas. We avoid puttng negatives in wrting. 
(Forida hospital) 
COBRA puts the major responsibilty of reportng on the 
tis,  reeiving hospita. Often
there is not the tie nor the sta to monitor this. " (Oklahoma hospita) 
A subsample of hospitas (29 of the 88 hospitas in the tota sample) 
were asked to 
explai or
voluntee why they did not report incidents of patient dumping to State or other authorities. 
Eighten--
al mhosapi.t a adistrtors--indicated that they were not awar to whom such report
ing should be  Two indicate that they prefer to work out such 
mattrs between hospi
involvig a thir 
tas rather than  par. Nine indicated that they "didn' t know" why reponing
was not mad to State or Feder authorities. 
One hospita also note that the responsibilty for reponing violations 
reste in receiving
hospitas. Such reportng would reuir proper monitoring and record keeping, as well as fol
wor 
low up  which expend resoures in short 
supply. 
Curntly HCFA dos not reui hospita to post notices in their emergency roms inform
ing patients of their rights under COBRA and indicating a number to 
cal in the event a viola
 tion has occured. The OCR provides notices to Hill-Bunon facilties to post in 
ERs and busi
ness offices statig, "Notice-- This Facilty is Legally Obligated to Serve the Community.
The notice explains that the facilty cannot deny emergency services, if it provides 
them, to
any person who need them but cannot pay. However, the notice does not provide a number
to call in the event a person has a complait. 
Practies persist which may subvert the intent of CO BRA alhough not directly violang its
provisions. 
Patient dumping is well hiddn. Outlying hospitas usually come up with an 
appropriate ' medcal reason to trsfer." (New York hospita) 
Hospitas ar gettng around COBRA by not mang an ER char when a patient ar
rives or when the patient is discharged frm 
the ER and told to go someplace else. 
(Mississippi hospital) 

Pur  decras. 
dumps have  But now there s a lot of gray aras. The trsferrg
hospita says they can t take car of the patient, but they get here and in our judgment 
the sendig hospital could have in fact taen car of 
them. We don t report these be
cause it is an ara of physician judgment, a gry ara. It seems that dumping contiues
but trsferrng hospitas ar carful to 
disguise the real reasons for the trsfer. 
(Forida hospita)

What is liely to happen is that the paredcs who must take an emergency case to a
hospita perform an informal trage of which ' 
socioeconomic status ' is a par, before 
selectig a receiving hospita." (California hospita)

A numbe of respondents 
offere the opinion that hospitas ar "gettng around" COBRA by
dbivielrn g patients durg ambulance trsporttion, trsferrng patients they maita ar 
trsferrg  sta
who may not be, 
tug  patients they "can t handle" when the reeiving hospita'
judgment is otherwe; and  away indigent patients before they get in the door. 
Although 41 of the hospita (49 
percent) reported never experiencing the diversion of patients
frm neary prvate hospita 
to their durg ambulce 
trsprttion, 20 (24 percent) caled
it a "occasional" occurnce, 13 (16 percent) called it a "sometie" problem and 9 (11 per
cent) labeled it a "fruent" occurnce. In a few cass, hospitas labeled this their "
major
problem. 
In the absence of statstially reliable informon on this probkm, HHS must rely 
heavily
on precise record keeping and reportng by hospital to 
fu/fB its responsibilites under Hill-
Burton and COBRA. Given the lack of such record 
keeping and reportng by Mspitals,
documented above, the ability of HHS to monitor 
and oversee this problem is jeopardid.  It is crtically importt for the HCFA and OCR to tae strong steps to strengthen the record
keeping and reportg requirements of hospitals which must form the fIrst layer of vigilance in 
this ara. Severa recommendations follow which could be used to begi addssing this issue.  RECOMMENDATIONS 
Ths insption identied a 
number of possible vulnerabilties in the 
identication of patient
dumping and the enforcement of the COBRA and Hill-Burn 
provisions which prohibit it.
Although we were unable to determne the incidence of patient dumping on a national level, 
we reommend that certn actions be taken in order to addrss those vulnerabilties. 
In an early alen to the Admstrtor of 
HCFA on this subject, we recommended that
other thgs, HCFA make reportg suspected violations of COBRA a condition of pa, racmiponag
tion or par of the provider agrement for all Medcar-parcipatig 
agr  hospitas. The HCFA
with this recommendation and this requirment is included in the NPRM released in 
wi  ma 
June and  be  par of the provider agreement. 
Based on our reord review of 25 hospitals which indicated that the Deparent 
s abilty to
conduct efficient compliance reviews might be 
jeoparzed by lack of necessar records ma
taed by hospitas, we have sent letter reports to the regional dictors of OCR and HCFA to
inorm them of our genera fidigs and specific results of the reord reviews conducte in
their regions. We note that efficient compliance 
reviews might reuir incrased recor keep
ing by hospita and a system-wide approach so that the pattern of 
referrs and trsfers
among hospitas in a given geogrphic area can be understoo fully. 
We fuer recommnd that the followig adtional measurs be taen: 
The HCFA and OCR should use  reui 
existig authority to  and ensur that hospitas 
post notices, such as those poste in Calorna, inormg patients of their rights under
COBRA and Hi-Buron in emergency rooms of Medcar-
parcipatig and Hil-Buron 
incras 
facilties, in order to  patient awarness of rights to access and to encourge the
reportg of violations. If dqmping is now camouflaged and hospitas 
ar reluctat to
report cass, afected pares may 
be mad more likely to report violations if they
awar of their rights and know to whom reportng should be mad. Curntly, 
OCR
provides such notices to Hi-Buron facilties. 
Considetion should be given to the use of joint notice in HCFNOCR shar facilties.
Al 
notices, in any event, should contan a local 
or toll-fr number to cal with complaints. 
The COBRA regturastiofnesr srh ould reuir that emergency rom reords clearly delineate
if a patent was 
shoul be mataed contaitno gw hraetl efvaacinltt iyn foorr mframti ownh a(itn cslouudrieg;  more,t ha otdr soffe trr slpogor
facty trsferr 
tation, 
to/from, reason for trsfer, etc. ). Optially, such record
would be mataned by 
both transferrg and receiving hospitas. This wil effectively
aid the OIG, HCFA and OCR in conducting compliance reviews to 
trsferr  ensur that al patients
trsferr 
to other emergency roms wer 
in stable condition. 
In adtion, as par of the intae process, al patients arvig at hospita emergency rooms  should be asked if they have previously requested treatment at another emergency room 
and were denied tratment or told to pursue treatment elsewher. Proper record keeping
concerning a patient s attempt to pursue treatment elsewhere wil also significantly aid
compliance reviews and enforcement effons in this 
ara, as well as raise awarness at the 
patient and provider level of the importance of this information. Lastly, 
hospitas should
be encourged to develop formal procedurs for ER sta in the event of a suspected case
of dumping. 
In order to incrase awarness and 
encourage reportng, dict outrach to professional
assoiations compose of emergency room and/or obstetrc personnel, such as the 
American College of Emergency Physicians (ACEP), should be un  rten 
to educate
ER pratitioners concerning rights and responsibilties under COBRA. In adtion, 
OCR
has suggeste that outrach be 
extended to community and advocacy 
progr  grups. Those
aras responsible for compliance, HCFA and OCR, should offer to send repre
sentatives to annual conventions and meetings to discuss COBRA and Hill-
Buron and
the issue of patient dumping. 
Positive effort have begun in this ara since the draf of this report was releas for 
Deparenta comment in May 1988. For example, in June 1988, a 
lett discussing
COBRA reuiments and the Deparent s commtmnt to enforcement in this ara
was signed by the HCFA Admnistrtor
, the Inspector Genera of IfS, and the Dirtor
of OCR and sent to adistrtors of all Medcar-
parcipatig hospita. Copies
those lettrs were 
alo sent to representatives of the American Medical Association, 
Amercan Osteopathc Assocation, National Association of Public Hospitas. 
Federa
tion of Amrican Health Systems, and the American 
Hospita Assocation. 
The HCFA should move to clafy the definition of what constitutes "stabilzation " and
emergent condition " such as the ACEP has done, thugh the ruemakg proess 
or as
a legislative initiative. Varous mecal 
associations (AMA, ACEP, JCAHO) should be
consulte in the development of those definitions. Because no such defition 
exists
unde COBRA, "gry" aras emerge and COBRA is mad vulnerable to abuse. Furer,
beause physicians may genuinely 
disagr on their responsibilties under COBRA, a
lack of unorm expetations exits in the mecal community as to the natu of those 
deas 
respnsibilties. As indicate above. this may 
the likelihoo that physicians will 
repo suspeted cases. 
The HCFA should work with OCR and OIG in this 
ara to ensur that there is a com
Dearnta 
mon  understading as to the meaning of these terms so that investigations
in ths ara 
ar consistent  APPENDIX 1 
STATE INITIATIVES IN PATIENT DUMPING AREA 
Defines  Includes
State  Mechanism  Emergency  OD Cas  Remedies 
Caorna 
Colora  Law  Yes  Yes  See Note 1.
Law  Yes  Yes  None
Florda*  Law 
None
Georgi 
Law  Yes  Yes  See Note 2.
Hawai  Law 
ilois  None
Law  Yes  None
Kentucky  Law  . No 
See Note 3.
Louisiaa*  Law  Yes  Yes  See Note 4.
Marland* 
Law 
See Note 5.
Masachusett*  Law  Yes  See Note 6.
Michigan  Law  Yes  None
Montaa 
Law 
None 
New Jerey  Regution 
None
New Yor*  Law 
See Note 7.
Orgon  Regution 
Yes  None 
Pennsylvana *  Law 
None 
Rhod Islad 
Calia  Law  Yes  None
South  Regution. 
None
Tennessee*  Law  Yes 
See Note 8.
Texas  Law  Yes  Yes  See Note 9.
Uta 
Law  Yes  None
Wisconsin  Law 
See Note 10. 
Wyomig 
Law  Yes  None 
.Passed in state after passage of COBRA in 1985.  Notes to Table 
Civi money penalties of no more than $10,00 per violation for inhibiting the reportng
of violations thugh that or intidation; mamum 
fme of $25,00 for violation of
anti-dumping for hospitas, $5,
00 maximum for individual physicians, with maximum
limit of $30,00 assesse against hospitas for the same 
circumstaces under State and
Fedra law. Provisions for crminal proeegs 
by the local distrct attorney and civil
proceegs 
brought by persons hared, as 
well. 
th 
$500 for each violation. A hospita with 
or more violations in one 12-month 
period is subject to suspension or revocation of license. 
Mimum'fine of $100 and mamum fme of $500. 
Civi money penalties of up to $5,00 for an officer or employee, or suspension frm
the state mecal assistace progr for hospitas in violation. 
Civi money penalties of up to' $1 00 for hospitas that violate provisions. 
In the event of a violation, the patient has the right to sue. 
Up to 1 year imprisonment and a $1 00 fie 
for pratitioners in violation. 
Offendig hospitas subject to suspension or revocation of license. 
Offense is a Class A misdmeanor, or 3rd degr felony if patient dies. 
10.  Fines of $1 00 for each offense.  APPENDIX 2

CALIFORNIA ANTI-DUMPING LEGISLATION  .. 
. .
. .  .. 
. . . '
.. . . .
Cdifornia 
Regular SeSSion

1987 New Law, Page 

S 153 
CALIFORNIA 
1U1ar S...1012 
Chapter 1240 . La, 
1987 
SeDate 1111 No. 12

. An act to amend 
1798.2  13i1 119, 119. 
of, to addSe tioSnsetions 1317.  110, 1198 172, and 
1317.
179.;.n 1 317"", 1317.6, 1317.  1, 1317
 1317  1317.3
to, and . to add Ch,p 1t3e1r7 .8, 1317.9, 1317.
2..5 (commen9cai,g  a.n 
Setion 179.9&.) to Par 
Divion 2. 
Coe, and to add1  Sofe tion 1.f  of, the Health ':d
rSeawettyi g.   ency medca1tso ethrev Pceena. _. 
' f  emerg
to 
De 
Stat 
01  tle.  01  do  euct as  fodow,s c
1.  0Urm 
. l  SECTON  Legitue fids 
! tht the proon(a ) of emergency mecal caaned  
3 pulic  is a
servce of 
great beDeft to  r'ia". 
CaI' 
It is

the protection of the health and saety of
4 .  hi 
tht a comprehenve and  quty
8 syem
. of emLrgeentcuy .m eadcla  servce be 
' 1  Th  provicdeod  
. 8 e.m (ebrJe ncy medca semces  Snds thtth th e  c: of.
. 9 deverg otherform of meacrea g rseeatcere    the 
. 10 .emergen Iebcea  mus be rey  in the stte, as
11 Uhour.a-dy  availe OD
and mus be 
provided to al
abty 
12'  d1es of  to pay. which is requied by extig
13. law.
14  Letu 
1b 
U(cI) pete  r8gnes 
the breath of 
11  the
16 fag CaID and undercompensted cae problem
UDas' 
1'1  peprovinde  s Theh iacdh dsietrivoen l oagf eC Dhupmbteerrs of
1189 .  .a(Ucod mofml teh n gH weaitthh S eano nS 1a7t9y7 .C9) too  Pisu ta 1n of  eDiirvtion
oay OD segment of the uncosmepecteed  cae
IIIlI  "epLrel teUm  th area of emergency 
fuer  The
believes  hS8!i"- II  physci
tht 
13  emergenc cae to anyone in nee
abty 
IS ca el of  to' pay. incu losp raes tig frm
. of 
patients. who have ' no thd-
soure of
26 payment or' for whom availe 
adeq co  paymeDt is grosy
uate  COver the  of providig such cae. The
18 Emergency Medca Servce. Fund 
created by Setin
of th ac woul provide lited fudig  puy
to 
the loa 
30 o&et  providers incu for treatig unnsred
31 
patients who arPve 8in  nee of emergenc c:e. Th 
3! prdes oaalys    sm act
compenstion for a  but
33 importt  of the laer 
pron  problem regadig
34 
35  of servce to the unmored
se. 
- ., 36 em(d)g Aesn ac r emste, dtchae  Legilatue fids tht providers of
mus ,
bear the higher  . .
' ' .. . 
--_.,.  .  ' -'---. .-.... - _. .' ..  ' ..  ,.
 .  . - ' : .''  : .
. ... .. . .. .. ' ........_-
Califoru!a S 12

a-sular S-Sl1o

1987' Nev Lava 
Pal- 5154 
1 expns 
par  of providig these servce and mus 
suer from
or no reimburment from 
3 II  may cofo th ei patients.
alowed to 
4 reburmencao ntmue, thes higher  and lower
could force may physcia 
8es,it- . M6
to. redce the. 'quaty and avaibilty
6. emergency medal.. servce  ent
to the de 
. 7:.  r'iaft!l 
9; LtLh. e(eees g Tiethue  risea feprreco,v ebidy i'g e. an tmiega.  otf hp alerg ftuiodnig,  tfhoer
10 .  vita.  Furer, it is th 
. .11  th  intent of the
. t 1J, medca seceth e source of fwdig of ep1ergency
be reted. . to the 
' 13 emergecies  incident of
equil imedte medca 
. 14. th ac wi levy. an additiona pety asceae.n Tthus,
15 trc: and ot;er 
fsihes  In th way, th, cots of emergency
. 16 . medca servce  be borne to a degree by 
. 17  relationp  crtig th  thse who
bav.. & . to  emergencies 
. 18 .  Seon 
. SEe. 1.  of t& Heath and Saty Co
1Q amendedto  131  'l 
sh
81.  1317. (a) Emrg  servce and cae 
. .!l 
pen  serv 
II prvided to any  feuestig .the  or care, or
ce or cae is reested 
' m mfor  wwhom  hi  pen  for any condition
14 iDur or ithlee'  sm at aanitys a ihn e dtahg efra otfy lo ls ionf Isi,  uorn dseerrious
: 25 chpter tht  and 
depaent  operates an emergency
26. whe  to provide emergency servce to the public
the. health faty hu approprite facities 
l;4;-d penn avale  th secea nd 
28.  ar. '  to provide 
, 29.  sh 
30,  (b) Iz. no. event  bath e 
emergency
. 31  ra,  be.  prvion  afoEted 
.31. s-ec e pmde  n  upon, or  boy, rtih,e
se tpy,r . erexligiio n. nationa 
med 
33 ciH'.,4Ihi  st 
p.. age,  ince  condition,
34 physca. or menta hadicap, 
ecnomic
3S serxtut t or abiltyc t:o tpaay.c foer m edca servce except to the
35. 
mecatl h a  such u age sex, preexitig
. 33'.8  mec:yc osnidgitniocna. to rt op hyscpa.r oor vmie.n ta hadicap
the. 
" 39 med'  of appropriate
cae to the patient. .
(c) Neithr 
th heath faty,. its employee 
Dor any  ---.- 
---.. 
. . : ...  ....  ': , . ' . "', . (.) "  . .- . -
C&l1forn1a S 12

"-gular 5..don 
1987 Hew Laws Page 5155

deti 
physci 
1 '  arg  or porterf  sh 
be lible in any
2 acon  out of a  refto  render 
3 servce or cae if the  is baedm eorgne ncy
on. exercig renale  the
. determinati
S penon is Dot suerig  Cae, tht the
from an emergency medcal
codition. or 
tht the (heath f'ty doe not have the
T approprite  quaed 
. 9  fs'teiersv ocre  persnnel avaible
8 reder thos 
(d) Emergency servce and cae sh 
10 withut Snt quonig  be rendered
the patient or any other penon 
. U to hi or 
. 11. her abilty, to pa therefor. However, the
. 12 psauteidntir. os r hhi  or her 1eg  y resnsble 
relative or
. 13  uectef Dan cagere eent to 
suly  pay therefor or
J4 o  rore cdreedtr weodrmtion
15. prmptl afer thfe saer vce 
are 
16 ' heth 
11 ch: p(ete)r I Id ao.'e not mataI Ubjec to the provions of
an emegency dearent, 
eaa its
18 . employee shlievereles exerci 
19' determe  emergen ez  sblhe  care to
whether aD  and  diect 
ID\  the pers selc enmeergee ncy cae to a neaby facity
. 21 which ca reder the  sh ast 
' D' pens sekig  servces, and  the
emergency cae in obtainin  the
13' sece inudg trrttion 
cicuce
servce in ever way
: St reDale UDer th 
tmon 
. IS . . (I). No ac or f'ty  or any .rese tea esblied'
16. by any heath  th 
licens under 
opeted by the feeral or stte governent, ac hapter, or
county, or
, 18 by the Regents of the Univerty of Caorn 
done or'
29. omttiedm whtiee a ttemptig to restate 
any persn who
sh 
30: is il  dager of los of lie 
impose any
31  ty upDo tuhne h ealth faty, the offcers members of
. . 32 th st,  or employee of the heath facity,
33 iIc1udg. ' lited 
t....  or ubupt nn otth e leeraxto  otehre  smtteem lboev eomf theen rte sue 
. . 34 
loa  or a
35 co
 ty, Rjf  e tfaeth" is  
Ip II 
3&'  u us  th 
in  setion, mean a
physci 
of  and sugeons, nun, 
. 38 employe of  heth  tredand
cupulona  faty who have ben 
. 39  restation 
heth  md hacve: b en desgnted
by the  atempt, in 
faty  of emergency,  --- 
. ..  ,' . 
. .
,-, .  .".;-.  .. .g.,.. 
 ' .--  . ". .  ..  "" . '. '.. ,  . .
Cal1fon1a 5

blUlar 
5...10G 
1987 Nev Laws 'al8 5156

retate 
to  persns who are in imedte dager of
2 los 
of lie. " 
. (h) Th seon sha 
not relieve I health facity ot any
duty otherw impose trg 
, 5  an  by law upon the heath facity
for the desgntion  of members of a rescue
tea 
OUr fIo r th prroeveio nt eor  m. atenace of equipment
. 'r :ta be. 
by' a 
S' . ' SEC 3  seon 1317.1 is adde to, th.f Heealt,h.  and 
s.ty Coe, to rea 
th  other 
10 1317.1. Unles  eotezt .  the
11 ' roUowm d  t:oDl sh'contrl the coi1ction of
arcl ' 
11 '
': (a) '  EmergeDcY -"Ce'  and cae" mea medcal
, 14 ' lCeeg, e  1''''.  tiOD, and evuation by  physci or,
15 to the atent petted 
by applicale Jaw  by other
, 16' '  pproprite'  pennel. under . the mpervoD of a
physci  to 
eoditiir  acdetere.   lar eixI.   ai emergenncye mcedc al 
18. '  or'  it doe, the cae,
sUer  apnd. hyit sci 
19 trtment, an'  by 8 
SJ relie or eJi1';"'. te the emerency medc: cotion,
II 'witf. the- Capaty of th Eaty;.
Emgen 
..2 I:I ' ; (b)' - magm,e dict:s c :ditiol" mea a medcal
condition  by acte syptms
suc:ent Seerty (mdudig  su tht 
abce  seere pai)  the
25'  of imedte medc:  reunably
exted  rest  attention cou1 
; 26, be  to  in an of the loUowig:
IS  (I): Plg the.patient.  heth m seOUi jeopady.
. (2) Seous impaent to booy cnmco:orD l. 
:. ; (3) Seous dysc:oD of mlya b oy  ti or
30  Ja"' mea 
Actve 
. (c) " at a  at which 
.'3 311'"  e 'i t(h1e)r  oTf tthher - foDoi wgDeqte ut1di   efF sa trer
is 
33 moter hota  to 
. 34s a(!)  A  pmroary  ptoo d 8el tihveeart. to the heath 
and
3S  of the patient or the unborn chd. 
osta" mea  hosta 
36 '  aD  with an emrgency
,' (d).
 enSt' liceea.s   th' stte depaent. 
e) --tate deparebny.t " me th Stae Deent
38' 
, 39' of Heath 
. 40 ' :. . (f) "Medca ha- mea a materi deterioration  -- 
.. ---- 
. . -.-- ..- 
' . 
,..  -,. .:,..    .:,. ..  ..: ' ..  .'. : . .,-. --( g_). . "  . . ". . .. , . .".  . ...: - '' .. -.----
Cd1forn1a 5 

legular 
5..81011 
1987 New Law. Page 5157

1 in :or jeopady 
uped chce to, a Patient s medcal condition or
, 2  efoar r ecvery. 
. Asce. the Board of Medca 
Bod" it  Quaty 
I::  .6 b :; .t !. p(ha) bilti wht&ie  tchaep ahioltsyi toaf  ther efaqtuy"i  mean those
is  to have as a
codition of its emergency medal servce permt and 
ed on Servce 
. . 8 
 Inventory Form 7041 Bled
. 9 bY the ghO aitn .d Development.
e Offce. of Statewde Health
with 
11. 
12 Ml'c de(iJ. terCooelr:ti Odl    mean the  nrbedyeerg  toefc lep hone mdo-p wiohenn, 
pres'b . to b. mtereatmdeztc  ay 
i 13: 
 tbe 
1.. , emerg  joitly by 

ol. tbe ncy  md  tbe  spty phJ'cW 
 mcludes review
__rn;PUJ
paent's medca 
 spty
irze .  aOQ
. 16..  trtmt  of  tbiJ p.aent  opil 
1'.  phJ'cW who i$ qrMed  pe.  by
or render
trtment  to live: 
1e'  tbe 12  order to  tlepaaent.
19.-: ' SEe. ,", Seon  iD  $Ibile 
added to 
re:1 3.1'7.2 is  th Heath and 
. 2ao.1    ty Cot, to 
1311.2 No peD neeg 
eme
:. D . hcaoe m ay .  ed &om a hostas etor vmceo tahnedr
be 
.: J3:  rason (suh u the pen
lDynoDmca 
serv 
14 .  .iDmiltY  .  pay. for any emergency  or cae) unes
15. .tro.f th  follpowig en  nditiOD ar met: 
. (a) The 
IS  .YQ!t  eced,  and evauated by a

is 
yf"'II if  pr  prr 
18  , izcladmg,

Je  COtatiOl 
Th  be 
' 19 
. (b 
 pecnaon  hu  with emergency
anmd tedr so . tht it ca be detterremre d with
31 reupaalee   "
31 .caus by th  prowbai biltyc, rteha  tah m  eca hoar ddelay
J20t 
33 th 
34  trerrg 
phys,"l1  at the 
3S aDdc)  A
ha obed the consnt to htohst at rhea rno tied
th revfg  by a
phyB"".  at  hosta aD coamtioD
38 ;  pMtb fet'.l ODDl c horsttea  thrte thtei pl en meets the hOspita'
33&. 8  trerl  to approprite
equipment n  to trea the pen.
ne 
(d) . hosta provide 
fo approprite  . .
Califorl1ia S 12

I.plar 
S...iOl1 
1981 Nev Law. Page 5158

1 penoei" . 
2 prdent physiceqiU iipnm thete  shaicel-  a "'reanable and
3 aerc:g ordi  milap  localty
or trer.
cae would use to efect the 
) Al the persn s pertent 
medcal recrds and
copies of al  diostc 
renalyth  approprite  test resuts which
& ue  avable  trerred 
are 
1 ' . (f) The rerds trrred  trwi th the person.
with the persn. include a 
Snmma  '. agned  by the tnemng
8 "Traper h
 ysci  conta 
190 "  Th  which  -rrraelerv lDt  inrmtion.
the  " sh 
rarm of  nmma 
11  minimiDum cceon ta the persn  nae, addres,  at a 
12 age,  sttu and meca condition; tsheex ,n raacee,
13 aad addres of  tr; 
th tranerrg 
depaent  doctor or emergency
14 ' tng perspnneeln au thorig the  the tie
15 an, date the  wu fi 
18:  hosta  presnted at the
It revig  the lWe of the phYsci 
trer 
hosta constig  att itehe
to the  and the 
. 18, aDd date of the consnt; the  trfer;
19 the. reuon for the trer;t ite rand  ddatee aoft tohen   
and' th 
signor  ased with  of the
th th signor' is 
reasnable
. medca probabilty, 
. hat retrhr    tht the  trecrerartegs n o medcal
to  patient. Neither the 
physici
sh 
' 23 Dor.  -rraer hospita  be requied to 
24 the  nmm  :. iDrmon  duplicate, in
contaed in
25 meca recrd 
S6  th the persn.
trerred re
(g) The trer confrm with regution esblied 
sa th deparent. .
. by trr
(h) Noth  sh 
in th seon 
apply to a 
29 a  fo mec: 
patient  trr
. 30  Noth  th seotn :sh  
33(1),   in 
:d=iht-atoif a paent' whetn r prohibit the 
. 31 
 th patent or the patient'
ve reques a  dihage 
, 31 
 or  and gives
34 mec' CaOD Sant dto cthee  .

ft."'
3S  or 
to read 
SEe. 5. Setion 1317.2 is adde to the Heath 
Co,  and
38 Saty 
' 1317.2 (a) A hosta which ha' a leg 
"38. whether impo  contr  obligation,
by sttute or by  to the extent
'39 of th contrtu  pa 
olbilitgeadti oD; to any th- payor,
4Q includig. but not  to. a heth matenace  ' .
-- .
---- 
. ,' '".-  '.  , .  . .
! " , . :  . .. -.' ' . (&) .  . -. --- -.-:.... . ,
California 5 12

legular Seldon 
1987 Mew Laws Page 5159

I orpn;'7ati ocn, he:alth  ca servce plan nonprofit hospita
2 sece pla, iner, 
or preferred provider organzation, 
or' UI employer to provide cae 
: . 34. Lr c ouunnty d
 er the  sped  for a patient
th  in Setion 
.. 5 reeive  te  1317.2
patient to the extent requied by the
:aplic:le sttue or by the  of the contract, or,
f 'whe the.hospta  unle  acpt a 
,8 it hu alep1 obligaiso. n, to  patient fOr whom
: 9, . DOt create a medca hatod.p.r vaisd se pceaed w hose trer wi
10 it sh mae approrite angements in Setion 1317.
"i. . for the patient's
sh 
, 12. .  coUDty hota  achpta a  
patient whose
13. trer wi not create a medca  sped
IS 
1" $eon.1317.2 aDd who is determed by the county to be
18 elgible, to .recve .health cue servces requied under
16 Par 
5. (commeuc:g with Setion 1700). of Divion 9
17. :dtIo  Wele aad. lmtutions COe, UDes the hospita
apprprite be 
. 18. . PeeDotJ hae   reqed  capaty, medca
. 19 '  or eqpment  proe cae 
. fD  acrdce  to  med  to the
patieut in  with acepted  prace.
221' 2Whe n who tCnOUrDt y whois ita isc urneb le to acpt a patient
Dot  a medca had u
f3 sped. 
in. Seon
. 1317.2 it sh mae 
approprite
argements for 
mae  th patient s cae., The fobolig ation to
argemeuu 
approprite'  in th
26 suvion' do  u. set 
Dot madate a 
mod  ' level of servce or' 
payment, 
28 '(caeng. the COQlty's obligations mder Par 5
1rth. Setion ' 1700) of.DivioD 9 of the
29 Wele  ca 
:list , aDd IntutSiones tCyo , create a 
of action, or
30.  .' countys 
31  with availe rto  emuanra .  county health
sb 
However, th
32 'county'  flexbity.  dUini,b 
rensbities  DOt  a county'
. 33.  UDder Par 5 (commencig with Setin
34 1100) of Divion 9 of th Wele and Intutions Coe
th reements . contaed in 
35. (orc. oeng  Chpter U
38 
with Setion 1+f).
sh 
(c).  hosita 
3&. meqelcDa tpi rrceueo nably reed inp rtohtveri dreerx peeerdnc n oefl g aoDod
. 38  tb-pfora th e cae of the 
patient.
40 :  4d)\ .Ay.  payor, includig, but .Dot lited  : . 
. ' . &  - '-
, ..  . ..
Ca11fl.mia S 12

Recular Se..ion 
1987 Mev Law. Page 5160

to,  health  matenace  organtion, health care 
sece pla iner, 
t Servce Pla nonprofit hosita 
preferred providecr oortgranttuio n, or employer which ha 
sttutory or '  obligation to provide or 
4. . a. . 
deYnn;sfyh  e mergency medca servce 'on beha of 
paent  contractu 
be lible, to the extent of the 
otbrligrartiogn t o-e patient, for the reasnale chages of the 
treati phyc: 
. 8  hospita and the  purt  for the 
th 
9' emergency servc: prOvided  to  arcle, 
sh 
10. esxecect eth t the patient  be resnsble for uncovered 
. ; 11  or any deductible or copayment obligation.
12 Notwthdig th seo  the libilty of a thd-par 
contrted with health cae providers 
. : 13. payor which ha  sh 
Ea th provion of tthhets  cemoerngetnrc yN soertvwce thdbie t shet 
..  114 
5 by th. termli toyf-   th-pa 
16. 1ecmI thne ce  of a,  payor tbt is licensed 
1" by th  mmc;qo;otnretr uor  the ComYn;c..;oner of
ha a  obligatin to provide 
J:8 .Co'r piDraetnms nan de mrgency meca servce under a 
.' 19 or sh 
., 2D' cotrct whirche acoc vecrc  esu wbsci be or an emoUee 
. . !1 ' detesrmhe d in  the term of tht cotract 
. 22 md  UDer the sole jurction of tht 
-' D licensg 
agency. 
ha a legal obligation to provide
S4,  (e) A hospitarwhich 
25 ca fo  ed by subdvion 
26- Seon 1a 3pa1tie1nt.. !u  to. th exent of its leg oblig(aat)io  of 
contr  tht 
impoed  to the extent of 
221  8 cotrtuby  osbtltiguattei oonr,  wbyh ich doe Dot acpt traners of, 
. . 29 or ma other appprite argements fo, medcaly 
trg 
: 30 satdlet epa. tpitus rint .vi otlhateiornt oof  sthh a rbcele l iobr lree gutions
for the 
hosta 
reaale ches of the  and 
. 31' trtig physci 
33  be  for prvidig servce and cae which 
provide by th recvig hosita.
34 shoud have 
. 35 (f) 
Subdvions  (d) md 
(e) do not apply to county 
Seo 
. 38 oblitions under  th We!fe and
-1700 of 
' :r  Co. 
IDtuticm 
sh 
re 
(I) Nothg in th seon  be interpreted to
38 ' 
39  hosta to mae arements for the care of 
do 
hosta 
40 a  whom the  not have a legal 
patient fo  .. 
.. 
..  .. .'  ': ' . .
California S 12

Ilegular S...1on 
1981 New Law. Page 5161

obligation to provide cae. 
SEC. 6. Setion 1317.3 is added to the Heath 
-3 Saety Coe. to read:  and
. 1317.3. . (a) AI & condition of 
5 sh tadroept,r i n cotation wi  licen.e, esatc , hospital
the medcal 
& aDd  protocla constent with th  policies
T' mgtioDS adpted heeunder.  arcle and
8. . (b) As  license, ea 
. 9 adopt a poal. ic-onpditrioon hibitioEg.  dition  hospita
10 of emergency  ca  in the provion
servce and  based on rae, ethcity,
origi 
. 111 2 megdiocna. D ationa  citienship, age, sex, preexig
condition. physca 
. 13. iDance sttu,  or menta hadicap,
ecnomic sttu, 
. 14 medcal servce, excet to the extenot r abiltcyi ctou ptaay cfoer
. IS such u age, se preexig medthcta la  
18 : pthhysca  opr merntao  n  hSl"  cap is medc:y csoingdnitciaonn,t or
17.  of approprite medcal cae to the 
patient.
As. L coDdition of 
18: . .  (c)  license, each hospita
.. t1o
  rewe tht physci who serve on anr " e 
" bas to
21. tthoe a h ocsap iotan'  s tehmee brgean cy rom caot  ra, to resnd
. 22 rmegieond.   of the patient'  ethc:ty,
S3 iqceD actoinondai toiroing,i , citienship, amge,e snext,a p reexUtig
14,  ssettu,, .  physical or  hadicap,
ecnomic sttu, 
.. 25 medca  except to the extenot r abiltcyi ctuo mpatya fcoer
.ge,  tht a 
, 26 such.  sex, 'preexig medca 
physca or menta hadicap  condition, or
21:. 8 th prvion  is medcaly signcant .
of approprite m 
cal cae to the patient.
29 If. contrac between. phryosci  
30' prvion of emergen  and hospita for the
coverge prestly
. 3311   evebDts thsa hh   ita &om imposig thos conditions, the
conditions 
be included in the 
33 lealy perible. Nothg in tchon ster oun s sonh as is
34 coed u reui 
tht any physci see OD 
35 c:" 
 an .'
. 36.. 
(d) AI. 
3' iarm  a condition of license, aU hosta sh
pens 
th  aU 
. 38  presnted to an emergency rom
represntatives if my 
39 unble to underd verbaa ro rp rwerstntet na nd the persn is
. CJ  COmmuncaon,
both ory an in wrtig. of 
the reasns for the traner  . ...  ----.--.  --.---' ' 
.-  ---. .
. .".  ..,",  (, 
, , ....: :,' '
Californa 5 

R8cular 58..10a 
1987 Hew La.. Pi,8 5162

ref 
1- or  to provide emergency 
servce and cae and
tthoe pterrrsn  s right to emergency servCe and care prior
3,  dihage 
or  without regard to abilty to 
pay.
Nothg m th subdvion requies noticati:)n of 
the
5. reasns for the traner in advance of the 
6 .r epennaonl eis  'unmpaned and th hospittar. fhear  mwahdeer ea
eSr: to 
locate, a reprntative, and beause
& Gf the persn s physca or menta conditio  notication
; 9. riI'niot  possble. Al hospita sha promiently 
10, jn their emergency rooms mOrmg the pubpliocs to fa  thsieginr
.11. . Both the poted signr aendf w  rtten communcation
COceg th 
: 11 .  traner or  to provide emergency
, sece 
: 13. and cae sha give th addres of the depaent
1" 0 ' u. the gwOvie rnent agency to cota -in the event the
15" penoD  to coz:pla abut 
the hospita' s conduct.
16- .  (ehIf a hota doe not tiely adopt the policies and
:1.  protocls reuied iD th arcle. the hospita.iD addition
18 ,  ;.J or reoctiOD of 11)' of its lice sh
to 
19 ,JUjee to'  to exce 
. be. Dot  one' thousd doll 
.2m1.,  .n(lolt,iOcOe ) '  . da"s tatfee rd eezteionnt- of 60 days' wrtten
fr the. 
. a! pac:es or. proocls reuied  tht th ahroscpli ta'
a. inequa unes  del  ebxyc uth   are
thtt  is  by the stte
depArent 
16. .  upon a showig of go an suc:ent 
sh  cause
. IS!. by t: hosta The notice'  includ a detaed
26 sttement of the stte depaent' 
s reans for 
its 
.dedteretionwt.. ha nid .w  sugogeseud' l be achc."tlaesl eto  the hospita'
to the state
, 3301.  os-r  EtUf) D dE atehh p haoracstlte a..ss' hpo licsi uabndm prio tocls reWred in
be  for approva to the
38  with 
adti  go' days of the depaent's
th arcle.
: 3334 .    of regtions under 
to red: 
SEe. 1. Setion 1311.4 is added to the Heath 
and
35:  Coe 
36  8Saty  8 4. (8) Al hosita sb mata 
" 1317. de  recrds of
31  tn. ma or' rev 
iDluelg 
Tra"  the
. 38 MMSemeotnim dum of  in SUbdvion (f) 
39 01 
 1.17.2 fo a peodr eofv tihg  yan
. 0  (&7 Al hosta  "u1lrn  or  trrs sh tie .  . '
---- _..
_.  ." .-- -.- - 
- , 
-..'.%-.-  
California S 12

Regular S..81on

1987 New Laws Page 5163

depaent anua reprt 
1 with the stte 
on form
2 preribe by the deparent 
which sha descrbe the
3 agegate 
number of !=aners made 
- "5 a ctrrdieg rtos th.e  persn  inance sttu , and received
and r 
11 for

li(cc)e T he reiVig  physi 
hospita and al  other
emergency room health  certed
8. prehosta  persnnel, and 
emergency 
personnel at the receivig
9 hosita who know of apparent violations sof h 
. 10 the  th arcle
regutions adopted  hereunder  and 
11 corresDdig  tnerrg  the
trmngpe rsnnel at the 
hosita and
12 the  hospita may, report 
13 violatioDS to the stte depaent  the apparent
on a form prescribe
14 by the stte depaent with 
one week followi 
IS ocence.  depaent sh  its
The stte  promptly send a
,16' copy of the form 
dmi";st
prite medca to the hospita a tretorr ragnd 
. 117  8 hosita md the lsotc  commtt. of the 
demeeprgle ncy medcal servces 
rmes 
. I1f& a genccy, opJ.t .dOtfb e'smte. oeg  factst  croenqcWludregs  tJtf  uethre
otber 
Qot 
ate
21  idzvetsttiOpIJ olr ent  tbe 
colJt:udes,  U1eritorioUSt obr 
 eciUZce
.2 22  3  tJt dios ba  uplJ 
itm/e cpue,e  ed by  its izvestigatiolJ 01  tbe  .Jegatioz would 
. Uf 
J  When two or more
p8DS requied to repo01 rt tbe  mrm.
. 26 appaent  jointly have knowledge of an
violation, a ,
tea sigle report may be mae 
membe of the  seleced by mutu  by a
28 racredacre  t agreement in
with. hospita protocls. 
Any individua
29 requied 
ropoto report by th setrioi  who digree with the
30 '  joint  setely
31  6.rert ha a  and du  to 
32
. A faure to  sh 
3343  cotute a violraetipornt w UiDtdhe rth et hm esaunbgd voifo Sne tion not
or. 1317.
33S8 .  r. e(td)e .N oa hpoit a goverent agency, or persn
penae, intute 
a c:viaction agai,
3f oirD re er moneta reli &o or otherw 
38  physci  cause any
ao  to a  or other persnnel for reportg in
. 39  fath an appaent  th 
arcle 
. 40 fttioDS  violation of  or. the
adopted here  der to the stte deparnt,  -- 
--- --- 
. .(-,.)- - -.. -.. 
--- ...- 
$/ 
California S 12

Recular Se..1oG

L8. 
1981 Nev  Pa.e 5164 
agency.
1 hospita medca st, or any other interesed par
2" governent 
(e) No hosita governent agency, or person sha
retate agait, penae, '
4 .  intitute a civi aceen agait,
S or recover moneta reliefr &e-mf,  or otherw. 
a physici  tran cause any
. 6 iDjiu to  who  to 
tr 
, 1:, wheD th physci deteres with  a patient
renable
trer 
8 medca probabilty, 
tht the  or delay causd by
10th e  wi create a medca had 
pen  to the person.
(f). Any  who violates subdvion 
11 Seon t1h31 7.4 is sujec to a civi money p(de)t oyr  (e) of
12 . lDorer eedyt esnp theodu sd tdhol l (810,s0h0)  pe violaotfio nno.
13 The- in  setion 
14  be in addition
other remedy provided by law.
15t Q. IDY 
depent sh 
publTih e- stte  on ID Umua bas
16- and  Legitue 
provide to the  a sttitical 
17  SUftft!l  by countY on the exent of. ecnomic trers
18' of emergetnrcyn  , 
hadous  pattierntrsi tnrh c fere quen of' medcaly
the  sttu of 
10  the pfatiieynt
and aD violations 
popultions 
!l determed by the' stte deparent debing 
22 natu of the violations  the
hospita iDvolved IDd 
ZJ taeu by the stte- dearent  th action
sh  iD respns. 
These 
sumftanes 
!4  Dot reea th identity of indiviua
, : 25' persnstrlDerred
ocee
. 16." " (h) Pr gs by th stte depaent to impose a
&n under Setion 
1317.3 or 1317.6, and proceedi
28 the bod. to impo a  shgs by
ane unde Setion 1317.6, 
29  ea(.8It.1-etea  8eear .J-'tea  ,ra" 4ia.  ef.ptSf'
BeiB  wM th  ei 
30 I 
 wH  CSa.-et8ia...4 1&119' 9c) ... .Pe. .  ei  Di' iaiaft 
31 a ef  ef"
d..  coIJducted 
3t  foovn (1) U. bota 
33 '  to COl2ta.
bMta  bu.es  propt  ibe, the
.:M  wjtb 18  tUyJ  the 
diMttro serrvce  0i1I  
3S.  il2t0tsice  iltelJotf iOproIptJ  to  Me  IJoti prothpe  o lie.  wrtig of 
38  COtmd  itotrhe   U reuested by
Ibe  itJ  the  buses  or:  the diiItonr'zs  desgnee, 
38  bold,  wjtb  30  cJys aD  colJrence, .t 
39 the 1'-;CO l2cJUlOl  oJ  wbicb  he or me  d/iemyca i, mod,

Uthe  ditors 
40  the  prpt  e.  or  the  .. 
California S 12

legular Session

1987 New Laws Page 5165

des  djIlJ 
the propoed fie, 
gnee  moces,  or 
or.se shal state with parcularty in wrtig hi 
2 be 
reDS  or ber
for  imed'ately 
thertfh t actio  and shal 
4- copy  bosita. If the hosita tiramet ses. 
to  the 
determtions mJa de Uter the UJrmsl 
cCOloJtesJ  :renca, e, the bosita  izrm 
6, .  the clrector " 
7. wrtdm wejtbc  Ol  15  buses  cBys  afer it recives the 
dkector's designee. The
. ; 98   boiaJ mby t&he d kelJctoor t" be reuior ed  inormal
10 coJUnmce  to requet  spane  d il th
11 actiOll. If ttoh COete sb  ositapr opo &e,  as
wrt:g t:t it  fa  to  lJoti the diector 
12 . 
 intellds  to  protes the propose Bne witb
13, the  prOpo lie 
th subdvion, the 
14 Il tieJ  sped  in thestt  deplent 
Ib  be  deeed  J1  order of  and 
Qot be subject to  nntj"i 
15  ew.
16 '  (S) Ifa basia) Qotiefuers   the  trtive  it iDtends to 
11 . CDtes  dUdkecteor ctor st:Jt  imedtely 
a.  proJ'  Iibel, t he

Upon Qotication, the 
. J8  QOti  the  Atomey  Geer 
. 19.  Attey  toGme r  eZ promptly  tde  aJ appropmte
cour of
" JD2  1 actiOlJ  JurctJ". Othe D plroopo r the  &e  iD  a. 
bcompoetet sbl  loted county iD wbicl  the 
is 
222  3.  AjlJa. 
14 Slid(3)  by prac tiOlJ  to  enfrc prpose  &e  sh
ditor tbe Attorney  Geer  aler  hospi  noties the 
r2IS6  r Jtu:t Jc.  of it! iDtent  is pto roCOluJtes ted the sJpro po  provlie.i  ODSIf   of

esestiOIJl  Ugthe stte  depsellt Ulder  hthea  v  the burden 
of 
29 tthbe  aJeged factbsy  supprpoplldeol'cre tof  the  the  deonccuer etd:t, 
the aJege  propo  &e 
330 1 &8  fats COtituted  vjo  tion for wJJcl

32 .  may bme  d the  Ulder  Seitison  appro131p7.3r, i1t3e17..4 ,  stte 
d1317.e6,  paent  proJ'  &e  buren of esmTbht! lig 
, 33.  MW  aJ  luve  the
34 .  tbpreppoderncoe qJl 1.d  tbe  dellce  t:t  the asesent of 
. 35 
&8  lbouJd be upheld If. basjU) tiely 
36  FlJoti. Optth ea #e:te ,  depaesnJt o f its decision  to  contes 
Qot be due md p.yable 
:3r8 .  un/es md Ulti ttheh d&ee ejuptsJeciz pt.r OCcdmg is termted 
of tbe 
39 '-t'r 
 Itte 
Acb'cm  proviolJ of 
(4)  broupt rmder  tbe  tl setion . . 
.- 
g, 
Cal1fonia 5 

I.ecul  Se..ion 
1987 Nev Laws Page 5166

_e .

tr 
and 
the earJjest possble da 
sebal  ab e  set for at  the cour calenda over al other 
. 2  preedence  on whicb eqUR or surior
4 preceexncpt ce is msattenp  cayto   gnted by J.w. '!lIe. for 
pro,cdi 
for 
'0 5 
 rensve p eadig and  bearg  any  such
the judge of the cour with the object 
e.  s.  be Jet by  atJ:e earliest 
1 Slurg  decolJ  as  to  bject  matter 
9p. oble ti di,.ift or reuce the
propose Ene 
(6)  the is imedately to eDSe 
10  actiolJ  nwer 
ate  ent sbal  tae
public recrds reilect  pro
11  tJt  the  cJnniD icuapr pmient reduce
12 m.t tle  propo  Jie  was or  stte
the 
. 13  (6)" bJ  lieu  of a  judiaal  submit 
. 14 depaent  and  the  bosita  may  jointly eject  to the
15' the matter 
 to bindig arUitrtJiotlJi,t
e arbitrtioniz  prwhoich eedcai, gs. The
16  pdepaeant es  arbitrtor desgnted by the
17  sl  ag upon A.ation in acpcrrdoceu writ h the 
eriC8 Arbitrtion 
18  md  The 
tion:S 
: 19 
 emblihed rues the 
2.  parabrietrst ion bear sb  be. set  witb  4$  dlys  So8f  days 
21  joint electiolJ. but  iD  no event les tb  arbitration 
of aD  arbitrtor.  The 
22 frm  the dlte of selection 
 d.ys if 
23 "bearg nuy be  COlJtiued up to
 15 arbnec itrtor shal 
the aritrtor s dicretion. Tbe decon  of al 
14  md 
25 be  upoa substative J.  sb T1be  bindig  on
pabae  s  review. 
review  sh
26  mbjeet  to  judia. evidelce to 
lbtt  to  wbether  there W& sub$aWtirJ bitrtor. 
2S8 . .m pport  the  &decodlJ'i  of  the  under 
by the  bo  to  impoJe  acca rEnde ce with 
. (1) 
30  s.0l  1311. sb  be  conducted  il Coe.1 of 
(commencig with 
SetiOlJ 11$0) oFPar 
31 Cbpter6 

331 3 ' D.iv ioSn  Ee. 8. of STietlte ion2  of1 3th1e 7.5 iGsov emamedlJt ded to the Heath and 
334'5 S aty Coe, to read th 
arcle and 
1317.5. (a) All aleged yiolatioDS of 
sha be investigated 
36 the regutions adopted hereunder 
deparent, 
stte  state  with the 
37 by the  depaent. The 
of the loCal EMS agency, may refer violations 
38 agreement  purt 
39 of th arcle to the slohc  EbMeS  caoienndCu)c ftoerd i nvestigation. 
40 The, investigation  ---
-.--.
. '
" . 
C.Ulorni. 5 
I..gular S...ion 
1987 New Laws Page 5167

1 procures establihed btyh th e state depaent 
and shal
2 be completed no later 
60 days after the report of 
apparent violaon is ,recived by the state deparent.
(b) At. the concuson of its investigation
S deparent  sh , the state
or the local E.\i agency 
6. aleged vaiolsatcione b y a physci  refer any.
7 quaty.  unes it ist od tehete bromarde dof  mth t cal
the
8 complait is without a reaonable bas. 
10 SaSeEtye .C 9.o ,S ettoio n r1e31a7.d6 :is  added to the Health and
6. 
. 11 ' 1317. (a) Hospita found by th stte- deparent
commtt 
12 . to' Dave  or to be respnsble for a 
purvtio lation of
arcle or the regutions 
, 113 4 sh  adopted  thereto
be subject to a civi  stte deparent
penaty by the 
IS il' 
an amount enoat  to excee twenty-five thousd dolls
16 (12 00) tor  bosita 
, 17 (b) Notwthtadig thv iolation.
setion, the diector
18 refer 
any aleged vilaon by a hospita owned and
19 operated 
by a health cae servce pIa involvig 
. fA  a plan
member or enrollee to the Deparent of 
Corprations
21 QDess the dbieact or determes the complat is without
22 reasnable 
The Deparent of Corprations shal
13 have sole authority and resnsbilty 
to enforce
14 arcle with  t. to vilations involvig hospita
. 25 owned an operated by heath cae servce pla in their
26  treatment of 
pIa members o  enrollee.
(c) Physci  bod 
found by the 
to have COmmtted,
28 or to be resnsble 
29 regu  ptoru, ar vtio lation ofs thh  arcle or the
ons adopted 
thereto 
be subject to
30 any and al peties which the bod 
may lawfy
31  imPo 
and may be subject to a civi 
32 in aDe aam ount not to exce Bve thoupesnda ty by the board
. 33 for  vioslahtio n. A civi peaaty impodsoel lu n(SdSe,rOO)
3345  sbuobddv isCh)n   Dot duplicate feera fies and the
eredt my feeral fie agai 
impo  a civi penaty
36  unde 
bot h subdvion. 
(d) Th 
Z1  may impose Bna when it 
fids any of
39 
40 (1) Th violation was knOwig or wi.
(2) The Violation was reanably liely  rest 
to 
in a  .-.- 
. .
_._.. .- 
. .
Cal1forua S 
I.cular 5...10n

1987 Nev Lav. Pal. 5168

r-medinard. 
(3) There are repeated violations'
(e) It is the intent of the Legilatue 
pri 
4 depaent ha 
that the state
respnsbilty for regctig 
conduct of hOspta  the
emergency deparents 
. 6 . Bnes imposed under th section should not be duapnldic athteadt
' 7 by additiona fi  impose by the feeral governent
. 8 .- rest of 
th  the conduct which constituted a violation of
. 9  setion. To efecte 
sh  thet Legilatu' 
10 Goveror  inrm the Seeta  s intent, the
arent 
eaent  of Health and Hum  of the feeral
' 111 2  of th  Servces of the
. 13 depaent  setionp aendt .y re qauess  the federal
to credt any 
agai  under
14: setion 
purtan y subseuent civi moneta 
penaty
115 6 Sety  tos Saeet iovni 1o8l6a otfi othen l.eeral Soial
. 17  Act 'sfohr th e 
lit
(f) There  ultive maxum 
thousd  be a  ases 
18.  hosta  doll (83, agait
. 19  under  00) in fies 
th arcle and under Setion 186 of the 
Seurty Act  sae 
: m feer 
 for the  cicumtaces.
21  eSectute 
122. .dTo. e    ent shth cu tive  nun..'m um lit, the state 
do both of the fonoWig:
(1) AI to stte-
pror to the fial
fies 
25 conclusaong, ain cludig judici review, if avaible, of
action 
a hospita by the federa Depaent
26  Hum 
Health and 
Servce under Setion 186 of 
feera So Sety  the
Act  sae cicutaces
(for the 
28  be 
fty deeed 
to have  a violation of 
29 the retioDS  th arcle
adopted hereunder. beaus of 
30 depazeDt  the state
31 aretuc  eactioen autdhoried  by th arcle), remit and
to the hosita with 30 
32 the afeser a  days aler coi1clwion of
action, 
33 to  tht theth t porton of the state fie necessar
"'.Pim 
34  cuultive  um lit is not
3S
. (2)' Imfeid tely credt' agai 
36 afer the  state fies asessed
avalet,  conclusaong, aiin cludig judici review I if
of. an action 
33T  8 Depaent  a hosita by the federal
of Health and Ht1an  Seces 
-39 -Seon 186 of the federa So Sety  under
agai  Act, which
40 rests in a Sne 
a hospita (for the sae  (j). 
California S 12

Regular Se88ion

Las 
1987 New  Page 5169 
1 cicumces fi
. deemed to have ben a violation of
2 th arcle 
3 beus  or the regations adopted hereunder
stte deparent 
of the  acton authnorie  cto
by
4 . arcle), the amount of the feera fie, 
S ase 
the  m.arim um lit is not exceed. 
7 puArn y c:uhltiveo  sita found by the stte depaent 
es esblied by the stte
to 
depaen' tto 

8 .  ve commtted a violation of 
9 or the retions  th arcle
adopted. hereunder may 
have its
10' emergency medca servce. permt 
l!  revoked or
11 sunded  depaent.
by the stte 
nti"ic medca 
13 bo(hw) Anyg  ly  trtive or  persnnel who
and intentionay Violates any provion of
'14 arcle, may be chged by the loc dict attorney with
1IS'6 a  miemeanor.
ea 
17 de(ip) aNeotnicta toicfm th oef  prviovinolsa toiofn t lohu nd by the state
arcle or 
18 reons  sh  the
deentad opted hereuner 
19  to the  be set by the stte
Joint Co  OI1 lor the
20 Acedtation of Hosita, 
seca  .. MI tbesmte emergency
l1ed  1o 
221 2 servce  .utbority,  and  emergency medcal
23 
agencies. ha 
My pel1 
who suers fpiecrsia a  md 
f'ty  any
14 medca  which suers a 
los u a resut of
25 ' \ violtion of th. atcle Qr the regutions adopted 
16 hterrreurdegr  may rever, in a civi acon agai 
the
or recivi hosita dages, renable
28 attrnerye sv feiegs a nd other approprite relief. Tranferrg
29 md 
hoita &om rwehifch  inpproprite 
30 
persns are mae or 
31 trrs  oE in violation of
th arcle and the regutions adopted hereunder
31 ,bter elirlre glo r the renable chles of the recvig
33  provig 
hospita for  the servce and cae
34 which should have ben provided Any persn
35 potentiy haed 
by a violation of 
th arcle 
36  . hereuder, or the loc dori cthte
retions adopted
37 atorn 
38 agai tohr eth ere Astntosrbnlye G  enera may brig a civi action
nti 
39 meca  hospita or  trative or
persanel, to enjoin tsheh v ioltion. and if the
40 bVUDol1 ises, the cour 
award reunable  . ,
 . . 
., 
. '
, .  . . ... .. . . , 
eal1fon1a S 

a.gular S..110G

1987 M8V Lavs 'age 5170

atiorn  fe. The provions of th subdviolni tar e in 
-r 
. 2 addition to other civi remedes .and do not  the 
3 av.ubilty 
of the other remedes. 
esblied  th 
. (k) The civi remedes  by  section do
eslied 
. 5 not apply to violations of any reuiments 
. 6 'ID 
county or coranety  agency. 
' . SEe. 10. ' Seon 131'1.7 js. aded to the Health and 
'1.
8 Saty C7o.e ,T toh    ' not prept 
9 1g3o17e.ren  arcle a.dcoge  any
With thei 
lQ  agencies  aturtehorrsity, 
. .11 . &om regutig. emergency cae or patient 
cludi . spc .
the impotion of lDore  duties,
. 11 
 coDSt  requients  th 
13.  with ther etion ' of  arcle' and its 
1.. implementig"  Any  . inconsent 
impo 
. 15 reuiementtsh .  by the Med-C progr 
preept" 
to Med.
116  7 beefciecs oTtor artctlueh- wei t h exttr 'rho spita and physci
18 enter into  relationsps with counties which 
19' impo mor stgent  corneqturieLments those 
sh 
10. con agreements 
11 . SEC 11. Steoti OrD e13a17d.8: is  added tc) the He  th and 
Co, 
12 Saty  th 
13.  . If any provion of  arcle is deced
" 1317.& 
!4 unwf 'Or unconstitutiotnba i n any judici action, the
15 re"".ini"1  provriones of  chapter sh rema
efft 
l! 
rr .
' SEe  Seon 1317.9 is added to the Heath and 
Co, 
28 SUty  to  sh 
29'  Th  dearent 
1317.9.  ba stte' '  adopt on an 
30 emerenc:  regutions to implement the provions
th are 
31. of  by July 1, 198.
31 
. SEe. 13 Stetoion  1r31e7.9a& isd ad:ded to the Health and 
Co, 
'33 Saty 
sh 
34 " 1317.9  Th arcle  not be consed 
(a) . 
3S alterg or repalg Setion 24 of the Buses and 
Profe
ns Coe. 
38  Noth 
(b) .  in, Setions 1317 et se. and 179.170 et 
. 38 .. se. sh prent.. physci, frm exercg hi or her 
ste 
3490  rpergofuetioonna  ajduodpgtmede npt uin rcotn ftcot  Swietoh nan y  or local
1317 et se. or  . .
" .
. ' - .. 
-- .- ---  --." '- ..". ._". ...;.:. .. .  . !'- --..,...-   -.. -.-   -,.-   :;  ., .

California 5 12

Regular Se8l1oc

La. 
1987 New  Page 5171 
1 179.170 et se., SO long as the judgment conform with
2 Setiom 1317, 1317.1, ID  except for subdvion (g)
3 SetiOD 1317.2 and  complice
loc we  te  scang  iz 
sute or 
5 bWithe  t the  regut:olJ would be  the
contrar to 
interests of the patient. . 
i.  SE.e.' .14. Chpter 2. (commencig, with Setion
. 179.9) 
"1'  is added to Par 1 .of Divion 
Co, to re  2. of the Health 
' 8 and Saety 
C1 U 
, 10.  TQ EwCENCY MEICASOVICES 
.. 13:  17W.98e  Ii- erl!sey Meeieal Serl"e  iW
J.aresy uea  iB  eMtt.  8SBe)'
. 15 uli_e,  t8 SM sle, '1' 8e8 .I'l'uI'ritea  e, .e
fw .w .. 
16  fe tI teimsW'semeftu I'e._ed 
T\RI'  er. 
18. .
19. Me179d.9,c &acbc oSWJtey rvce FUld,  lDY embJi
 Emergency
bO  reslution by 
lbe  upon adopt:oll of 
. m 
 avaJe 01
I 11  mpri.  rmbu71e nmmoleiey nts i'z the  Fud shal 

for  the reuied by
Amd  drninic:
cbter.  71e  sb  be  tered by  acl  adcmoWtJetyr, 
S1'  Jexpbt tmbt  etcay mcoWdJit y eJecq.to  luve the 
 sute 
t servce program DUyal 
14 
IS b.ve  iaEamteer.g el1cy MetC6 Servce Furd .drnineijfetcetr etdo  
the 
rebun  an.f'ini" 
26  by  Co  of termg the  lid sb

, 2IS 9 pof  htyhes c/ii d.by   Ththe e fud sup  hto  b10e  peurcntt iofe  d toth e reiabmuorWseJt 
8e"ia.- for paents who do not mae 
. 30 
ieea 
ISMes iaettea . te 
p'1ay'm8ei-nt i9folr 8
  S ef e=rsency m.. fee d
 cal servce 
31 
32  el'''_81A1A t  ,r8.HwesI8Il Yfe ite   paj"Ieeesef-et   8At e th
33  eril ef Sep\.ieea 
34  th fw. .. th  ,asallt Ranfer

,ra ._SM ee8"-iRes  Seesans 
putL'.  md lO oiB ther emergelJcte y 1m31e7d.9c&a, l isaeelrtv:ch"es 
36 
of
38 tb mODey inde tetrhmeed b yf 
ud sh bacl e diCtrObWu2tetyd. T wtoo-thrd  physicia
39 Ctohr e mersene servce 
40  physci  provided. by al physicia, except
hosita 
empl()yed by county  or ditrct  ' .
. .
... -.
"""
. . ' . :':  ,.:  .. 
CaUforna 
S 12
1.lUlar 
S...1011 
1987 Kev Law. Pa.. 5172

Ospit8tr: hi  eneral aCute Ca  hospita tht provide
2.. tbiaec : or comprehensve emergency servces up to the
. 3  the patint is stbiled and one-thd of the fud
, sh 
othrb.e  ditrbute..  eurspsrasMtc  'PiMt for 
medcal
.. 50 ,qetermeze TgeZJcy bye.cb  ; servce pure$ 
. 6.- sh  'Pe source. of the money 
e fUd  be  COWlty. 
1.  p1.,  th penaty  ent made for 
" 8,.  as provided in Setion 146 of the Pena Code. 
9. . Me..el9l 8h.  =IR  i sM irwas88 ef 4!  arleftey 
. 10  ge,.  \.ec3  ,ePisrmea 
11:  Heal. Ser\;eeec    It Yt eftt
eeft..e  ei aepA 
1132  ...   ,..,,taefrte. 8w1H  ei Y,t Pi-;aJteeM ef.et8 8caae 8.fe .e u&!lMr ttee  7Ja!alei- .. 'efre  81. 
14. 
15.  1'f.9b. S.t  &cD  ep.t  eBt ei  Healtahl Sidel.'i la!l,
. 14  COWlty  Janua 
emUsg  shO J2 
11'%8   th 9L8, eagndi,t uC?en each Janua 1 thereafer,  report to
' on theS imepcleem entation and sttu of the
19. ,Emergency Medc:  Fund., The reprt
1201. m clud, but Dot be limJted .to, al of the foUowm:
(1) The fud balc: 
and the amounf of moneys
12.diburunder  progr  physci 
the  to  Pur.8al!i..-
for other emergency medca servce  and 
. 231  4 - (2). Thepattem and dibution of cla and the
2!S fpe centage of c:1a 
paid to thos submitted
dibur
(3) The amount of moneys avaible to be 
' physci  8al!it.
, the doll amount of the tota 
rAI"'  surbembiedu arnd the percentae at which
IS alowable 
329 0.    were 
suc:  th 
(4) A stement of  procures 
retory  policies  and
3L  acon taeD to implemet and nm 
31 prosr  th  the
33 1'7.9un der  Phcy:hsapct:e rw. ig  reibur 
(a)  to be 
sb 
. 30  sumit te  Se'8rE8at thei los incued due
te 
35, . to patients who do DOt' mae any paypmeant  for servces
38 and fo whomp hDyO srlceio nsshbsl e srteDdb, u r.  m-es any
paypmte. tN o  be  te
3389 40   of thos 
40. re(lbW) Ibf,l yaf eer xpapym peanyt mfremnt  t&he ofu dth, ea  pphaYtDitc : can
or a  ., ' , ,  _..
; ' . ''  .. ".'  ,. ,-  :'; &' '-  . -.. :  .." - ,' .'.  ,  : , ..--. 
Calilornia S 12 
Regular Sudan 
1987 Nev Law. Page 5173 
1 reDSble pa,  sh 
then the physicia  contiue
mae efort 
3 prous  to, recive payment, notwthtadig
payment from the  afer 
physci  fud.  H,  payment !rom
' 4:  the fud, a  is reUnbuned by 
, , 5 rensble  physci sh nao tpiat ient or a
payor p the 
. : 1  fDepaA. e'  sueBot ei nHe aIt(:'l aSie"" ,  fwd  fudan sd hth e pthhe  ysici"
acrdgly. II  of  to, the  be reduced
' the event there is not a 
t. samian  subseuent
cl fo" reiburment 
tbfucfpUof Ia tto th  of servces by
!Os '  physci with
schhpt er by the 
1J' . ODe 
 e, qth,e  physci  reimbur the fud in an
: 12 amount'  to the amount' colletcthed  from the 
patient
13,  F other, payor,  but not, more  the amount of
14 reburment reved &om the fud for cae of tht 
patient.
' 15 
18,  '" (cl)'o F or th P  of th chpter, reimbument
IT. . for  mcued due to paents for whom no payment
recved  rested 
: 18, . is  sh be  to the followig: 
: 129,: 0 the(IrY e isP 8atiie'nmts i,bfolre 'w hom the physctih bda- pinquaied  
" .U  paent., prvate or public  soure
: of 
rebat 
, '! a3.  , ..,. (2);. Patients fofro wrh  tmh eth es eprhvycscei ' perxopvtsi dtoe rde cive
I (3) 
Patts lo whom the physci ha 
14  biled for
25 ptahym peaa or.. ha.. bied, a. reDSble 
26'  private or public
(4) Patients Co whom the physci ha 
made
28, renable efar to collect payment. 
29 ' 
nai"", 
ben 
(5) which have  rejected for payment by
3-1th e praoPtienUlt lanlod  awny re nsble thd pa.
For . of th chpter, rej  tion mea either of
. 32 the 
Act 
33' : t,.h (A ).  notication frm the pen, resnsble
, 34  pa,. or IOvernta 
agency tht no payment
. 3356,  wi be mae lor the servce rendered by the provider,
. (B) Th pueofsi 
phcf  month' 
tie frm the date the 
ha bied 
:r  eirb  the patient and mae reaonable
38 fb ptoa ob t reburment frm 
the resnsble
38 
or 'governenta ' agencies, and durg
physci ha  be 
04' ,wbich.'tfe the  not  wholly, or in par,  ----  ---
. -- 
' , '

..  ..  ,--  ..  .. .. 
Cal1for1la S 12

cular S..doft

1987 N.v Lav. Page 5174

1 reibured for providig the servceS rendered.
(d) A 
litig of patient naes sha accmpany
3 physici's submion, 
" fu  and those naes sha 
confdentity  be given
achJnterig
protections by the 
. 5 ' agency. ' 
6 ' 9B One-th of 
1797. sh  the Emergency Medcal
1. Servces Fund 
be  par_eftt
' 8  eipP8,sfteftatc  adsisbuln' ieL,   sefies  Ollif'3P'a
Meseal .  M. 
. 9 
 t_etJ CeRl- sS8  aee8ef, aanec 
Nluii-i!is8  See8sa  Weec
, 1l1O't.  
 tJ-M-ah l8s  Csse,ei  1'1'81'S1'888  ei 4! 
 a,prel'sf88ftate
12.  ei  elllerlese)" Je v.eel r8ftaefta iekal 
piluuiil ra tu I'a seau. 
13  for other  emergency  meccal S#rvces 
, 14" 
15, 1797.98.d et(earme)d  bIyt  is the inteeachn  t ofC tOhUel tyL. egilatue 
. 16 liplied  admtion  tht a
cot-eftcient system. of  of
. 17 ' mchpatuerm b e develope .,  aep  eftt  so that the
1&  amount of fud! may be utied to reimbure 
19 physic: and hospta 
 aefo,r -ot.heer, at  emergency  medcal 
nm;"ist
, 220.1 M-!mcse 
h espubres.   proThce edures and tie schedeurliegs  faogre nthcey
22 ' submJon and processg 9f propose reiburment
reues  physci 
. t3:- submitted by,  88!pitti 
The 
fa diburent 
scheduJe shal provide 
' U 
 of al avaiable
25 money in the fud at lea anuay on a pro rata bas to
26 al appli  tJ who have submitted acate 
and complete
data: for payment by a date to be esblihed by 
adrterig  the 
ae,M to_eat  It is anticipated that
28 
' 29' the moneYs in the Emergaegenncy.c  y Medca Servces Fund
30 wi be 
sucient to meet only a &aon of the requests
31 for reburment &om physci 
32 cicutace"  .c8M Jt8e8r!,iitg   . In
sh  e8'  agency
33  the  aepa.
, 34' paymeeqnut iftarbmly  tphreo rfauted p iasy bmaenst Ju spoo nth tth et hme aagmntouudnet  ooff 
3S the physcia' 
dnirder 8S!lital'  nees,  aepWHf!ftt
loss. The

may, 
38  and docegn agtenacy tion  request records
reiburment  to support ' the amounts of
. 38  reqesed by 
8s!l'itat, 
aepw !lieftt admterphyisigcia n 8M 
' 39' and the 
 may review
40 'and audit such recrds tor accuracaygen.cy  Reimbunements  -- 
.. 
., '%  -...-.-
. ,  , .
, ,
Californa S 

Recular S...ion

1987 New Laws Page 5175

1 reuesed 
and' reimburments 
made tht 
are not
2 suported by recrds may be denied to and recuped
physci  tti
3 from  ell i  . Physcia ae!pitt
ifonuntd eto  submi8tM  reques for reimburse.m 8M ent 
tht are
or unpported by recrds 
sumittg  may be excluded
from  Ea  futue requests for reimburment.
(b) 
provitdher  oE healths sher vces whi.ch recei.ves
8 payment under  chpter  mata
, 9 rerds  lerv  keep and 
of the  redered 
the penon to whom
10 . rendered' the date, and any. additiona inormon 
.e,  Lest  the 
arrn;n;q;e
11  may, by reguation,
12 requie, for a  rig  theagereJcy yeu 
from the date the
1134 le rvcewa prpoeriovd  idedoE  
Dug 
(c)  norm workig hour, 
.e'.8Beft 
15  M.Y!P2rrT;n;""D te rg  .geJCY  mays  mora peh aynsyct hei i'n  tion and 
16  tion of . choasp ita' s boks and
, 17 rerds neeed to  out th provions of 
18 A prroveidierb  ur  ftah  chpter.
who ha knowigly submitted a  request
. 19: for  sh" be guty of civi fraud.
. m  15. Setin 
2212 .is   SaEme. en to rea 179  oE  the Heath and Saety Coe
179. . (a) Th medcal diection and 
magement of
23 81 emergency medca servce syem sh 
!4  be under the 
the medcal diector of the 
mecal contrl  oE sh  mataloc EMS
2!' agency. Th medca control  be  in the 
: 26  rTD""er: 
followig 
(1) Prostively by wrtten medcal 
2B procedures to  stdads  policies and
29.  provide.  for patient cae.
Imedtely 
(2)  by diect 
voice cemmumcation
. 30 betwee a certed EM-
P or EM.n and a bas hospita
emrgency physci 
31. .  an authoried regitered Dun
32 
the event of teporar unvaibilty 
and,' in 
33 commumcaoDS, by  of voice
utition by aD EM.P or EM.
334S  oPf UauJthto rtioed  SWrtetetn ioordner.s  a1nd7 po9lic8ies4 es.blihed
36 
ca(3 )a nRde tcro  ntiutiivgel ye dbuy cmetani on.  ot medca audit of field 
38  l sh 
w. h(bi)  Medcal contr  be with an EM syem
. 39  m;";",
complies with the  UI stadads adopted
the authority. and which is establihed and implemented  ----...----- 
, ,
Cal1foru1.a S 12

RelUlar S...1oa

1981 Nev Lavs P 
I. 5176

the local EMS agency. 
1 by 
In the event a medical diector of a 
bas 
(c)  station
questons the medical effect of a policy of a local E
'" agency, the medca diector of 
the bas station shal
submit a wrtten statement to 
the medca diector of 
the
6 loe EM agency' requestig 
a review by a panel of
7 medca diectors of other bue sttions. 
8 the  Upon reeipt

reques the medcal diector of  loc EM 
agency
. 9 
10 dsh iectors' oaf9" "  basp romptly  convene a pael of medcal
sstthi ons to evaluate the wrtten 
11 sttement. The panel  be compo of al. the medcal
12 diectors of the bas sttions in the 
. 13 loc  lreigtio n, except tht the
EMS medcal diector may  the pael 
1. mebers. to five
15  Th subdvion sh. rem 
16 authority adopsts muorbe cdompvrehiin eoefnects vne r.eongl.y u ti!oun. ntsi  tthhet
11 sunee th 
SEe. 
1&' .  16.' Setion 1198.110 of th Heath and Saety
19 Coe 
is amended to read 
20.  tr1e19r1 10. A Ioc EMS agency may develop 
trge and
. 21  prtocls to fatate prompt delivery of patients
22. to approprite desgnted fac:ties 
with and without its
area of Jurction. 
sh  Consdsehra tions in desgntig a
24 fac:ty  include, but  not be lited 
2256 fo llowig: to, the
rt  (a) A genera acute cae hosita. constent abilty to
provide on-cal physcian and servce for al 
emergency
22B9 p atients regardles of abilty to 
pay.
(b) The suciency of hospta proures 
. 30 tht al  to ensUre
patients who come to the emegency deparent
31 are  YA",ined and evaluated to determe 
whether or not 
332 3an  emergency condition exi.
. (cr) eTheu hosiitea. ments.

s complice with loc 
34 protoc  gudelies and trer  E.'vS
agreement
. 36 
CSoE e. 11., Setion 1198.112 of the Heath and Safety
is amended to read: 
38 119.  loc EM 
(a) The  agency sh ; 
39 Iy -I esbli gudelies and stadads for ce,o  mJapnle1tliaon
40 and operation of fonn 
traner agreements between  .j 

-------.- 
. : _. - 
. ,.  . ....  ...  .. ., ;: 
Cal1fornia S 12

Regular S...1on

1987 New Law. Page 
 5177 
1 hosita  vag 
with 
2 Juction  levels of care in the area of
of the loc EMS agency constent with the
3 provions of 
4. Chpter 5  Setions 1317 to 1317.9a, inclwive, and
(commencig with Setion 
S EM  sh  1798). Each local
agency 
solicit and consder public comment in 
g gudelies 
. 6  and stadads. These gudelies
7 iDlude provion for suggested 
the ty.  wrtten agreements for
9 requiementofs pa.en t,o  f inteirrthialo pastiepnt ita caec,u e treatments,
trer  and asiated
10 logitics for 
pant :;. Ie 
t evaluation. and montorig of 
11  the
al!ftf)' 
lUadtn  aeeee.M ar iBiW  sM .. 
 esta8 
. 1123  
 r8eepeelarasu8lW!e  fewH th 
 leeS8a  e8  tr.eekatr!eeffttete3 
14  aa8ptea  eepM'aelU 
iees8a i31'.9 '8\"eP., tBh 
 I  PW:!HAnt
. IS 
 aeees,&I DSai  e8 .e
.8&_ea.
. 16 
 (b) Notwthdig 
provions of subdvion 
(a),
1189  aaDdc tien  a.cddaitein  htoo tshpe iptrao vliionCs oef S etion 1317, a general
under Chpter 2
20. ' (aoD1enc: with Seon l2) of Divion 2 sh 
II trer' a  not
persn for nonmedcal reMOns 
12 heth faty unes  to 1D0ther
13. persn.  tht. other tfraetyr  reivig the
agee in advlDce of the 
war!r.cr. Draf  t:rM.ai.fi to accept the
Sf  awaelil;.J  tM. 8e
atl.jeet  ,Hsal; aear,. 
SEC. 18. SetiOD 1798.D is 
2IS  8S aety Co, to read added to the Health and
tr1e79r. D. Any 
aleged violations of loc EM 
. 29  agency
protocls, Igeud elies, or agreements M.
es8l  It te 
30  8leaey.  if-:e,slaS&ft
31  e8IBpletea ..ui  eM  &I9e . . 8i  a,pareftt
32  81.s8ft  rep8rtelao. I i th  th' ftl)l 
33. evalUted by  EM  eM  shai
334 5..e m:s  h thaae  cotnhe cluded tht a .v.enicoy.l IaF tion hthae   olocceald E,MS 
whatever 
correetive 
action it deems
36 appropri with  jurction. 
dict  its  includig referral to
37 the 
attorney under Setions 1798.
38. ID sh noti  20 and 1798.
the State Deparent of 
39 if it  Health Servce
concludes tht my violation of Setions 
lusve, ha ocured.  1317 to
1317  --------.--
, . . " .. 
California S 12

Regular Sel8ioa

1987 Nev Law. Pa'8 5178

SEC. 19.  tion 1798.2 of the ' Health and Safety
2 Coe is amended to read:
.3 
' 1798.  Whenever any person who ha engaged
or 
.. is about to engage, in any act '
wi  practi:e which
contshtu tes, or  constitute, a violation of any proviion
6.. of  divion, the rueIs oan d regutions 
trr  promulgated
' 1 purt thereto, . or  EMS agenc madated 
. S. protocls, gudelies, or  agreements, the
, 9.. superior Cour in and for the county wherei 
10 pratice tae plae or  the acts or
ctn  are about to tae place may issue
11' an iD  or other approprte order restraig the 
12 conduct 01X application or the authority, the Attorney

13 Geeral 
preeo r . the dittrhct  attomeys hof  the county. The 
' under- setion 
14  be govemed by 
15, Chpter 3 (commencig with Setion
re  25) of Title 7 of
16 Puanrd 2e orft gth es hCo e orfe Cqiveid P rocedure, excet tht no 
11.  be 
. 18.  SEC 20. . Setion 146 is added to the Pena Coe, to
19 
asents 
fA 146.  m addition to the  Setion 
levied by 
asm1
21 146 an 
im'8f1eS  of one dollar 
22  additiona impoent  iI 
(81)  bo  county upon the 
;:. may be 
 by  eacb 
223 4 aadopstioleJ ofn  t,  reJutiOlJ by  tht he  01 supervors. An
impose by  setion sha 
25  .. Yt  Treal  be  feP'/&f'sea
!BeRth  se,e.!it 
26  eiei eee rlesey Ue8:eti SefS't 'iees  erefe ates  Se!i ese!!
98a ei  Health  gak  Cese. colel, ected and 
rr  M8
(commencig with 
28  Sdibuer tiOlJ  as  providiM  Chapter  1. 
329 0 Co. 17998) ofDiviolJ  1.  olthe Health and Safety
31
put  reiburment 
SEe. 21. (a) No  is requied by ths
32 ac  to, Setion 6 of Arcle xm B 
Cami  of the
33. 
Constitution for thos cots which may be
34 mCUed by a loc agcenrcye o r school ditrct beause ths 
. 3S ac creates a new  or inction, chages 
cre  the
38 d8tiOD of  intion, 
cre  or  changes the penalty
cre 
for a 
or inaction, or elbn'"A tes a  or.
38 iDction.
39 (b)' The Lelilatue  of th act to be
40  intends Setion  cert 
declaatory of exitig law which -requies  ---.- --.,' .- -.'.- .-- . . ..----..-.-.-.  ..  _.. .
. . , ... ....-.-  .-. ..-..  .- ..  .-...
California 5 12

legular Se.sion

1987 Nev L8WI Page 5179

1 IOvernenta ' payors, includig counties under Par 5 
2 (commencig with Setion 17(0) of Divion 9 
of the 
WeJIare and Intitutions Coe, to provide . medcal care,
.. includig  cert 
emergency medcal 
servces, to 
patients unble to pay for medcal servces. Therefore, it
is not the intent .of the Legibue in enactig Setion 5
of th.  madate 
act" to  either a Dew program or higher
level of servce and 
9 reqed  th  therefore DO reimbWp'uemretn't is
by  . provions 
act for these
10 Setion 6 of Arcle XI B of the Caorn Constitution. 
Governent
Notwthdig  tion 17610 of the 
. a. Coe, it the Commicfton on State Mandates determes
13 tht" th act conta other Co madated by the state,
reburment 
. 14  co stho lo cal agencies and school 
15 those  tdoit rPctas rfor
be made pursut 
..,16 
1commencig with Setion 175() of Divion" of Title 
cl 
Governent Coe. If 
1'% I of the  the statewide cost of the
18 
lor reiburment doe not excee five hsuhndred 
19- thousd doll (8S,OO).. reimburment 
th 
made &om  imc Fund.
'0', .-- -. - .
 State Mandates 
. 1

7. 1981

Approved, S.pC..ber  APPENDIX 3 
AGENCY COMMENTS TO THE DRAFT REPORT  DEPART.\1E:'T OF HEALTH &. HLiM:\:\ SERVICES 
Public Hec Ith Service 
".""0 
Memorandum 
JuL. I 5 198 
Date 
Deputy Assistant Secretary for Health Operations and

Director 
, Office of Management 
CD: 
OIG Draft Report "Patient Duping After 
S ub)ect  and the Perspect i ves of  Assessing the Incidence
Heal th Care Profess ionals " Q\1-12-88-00830 
Assistant Inspector General for Analysis

and Inspections, OS

We have reviewed the subject draft report and concur wi 
th its
conc 1 us ions and recommenda t ions. 
Wi 1 ford J. Forbush  ,//,:
..." . -. ....  .',  " ":,,:.,,.  - --
Ut.ART,"tE.'TOf HEALTH" Ht..'tA:\ SERVICES 
OHelce. o/! !h""e0 Se :re:ar.
Wasnlngton . D C 2C20' 
. 'i 
!)l 
MEMORANDUM  Orfl r CF :. :  ''- f' 
DIG 
8aa JUL .t l3 A. 14 9' 

IG. 
DATE  . June 13. 1988 
AIG-
9'V
 AD:\t
FROM  AUdr  y F. Mo 
OGCrIG
Director  EX SEC 
Office for Civil Rights

DATE SE

SUBJECT:  OIG Draft Report: "
Patient Dumping After COBRA:
Assessing the Incidence and the Perspectives of Heal 

Care Professionals,
 OAI-12-00830 
Richard P. Kusserow

Inspector General
. Office of the 
Inspector General 
We have completed the review of the OIG Draft Report

entitled " 
Patient Dumping After COBRA: . Assessing the
Incidence and the Perspect 
ves of Health Care

Professionals, 
. and submit the following comments for
consideration in the preparation of the final 
document. 
COMMNTS: 
Page 2: 
The first full paragraph refers to criticism 
of OCR for not providing facilities with

formal technical assistance regarding their

obligations under Hill-Burton. 
We believe

that mention should be made of 

efforts in this regard.  some. of OCR'

Although OCR has not
been able to provide techncal assistance to
every facili't, our voluntary compliance

acti vi 
tie. have provided awareness and 
technical assistance to many hospitals and

o'ter segments of the communi't concerning

their rights and the obligations of hospitals

under the Hill-Burton Act. 
For example, in

one of our Regional Offices, the fOllowing

contacts and interviews have been held with

various groups in an effort to understand

their perspective of the problems of patient

dumping, as well as to explain the role of

OCR and the obligations of hospitals:
 .. . 
Page 2

Representatives from a union local of

the Hospi tal Worke  ' s Union 
Representatives of a local Congressman

office 
The President of t 
e Health Federation

of Philadelphia

An Assistant Dean
, School of Medic

Director of Local Governent Affairs at 
versi ty 
a maj or Uni 
Administrators 
Hospi tal 
Also, in another Regional Office, community

based organizations that represent

consti tuencies 
that are most likely to. be
dumped" have been participants in meetings

wi th OCR staff. The groups included the
Chicago Urban League, Mexican American Legal 
Defense and Education Fund
, Traveler AID and

Immigrant Society, Chicago NAACP, and the

American Refugee Committee. 
convened a "  In 1987, OCR

Patient Dumping
" seminar designed
to inform local community and advocacy groups

of the Hill-Burton obligations of hospitals.
As a result of this seminar

, OCR developed a

patient dumping" Task Force headed by the

Chicago Urban League. 
The Task Force assumed

the responsibi1i ty, 
through its memberships

and varied constituencies, to inform OCR of

patient dumping" problems in the Chicago

MetropOlitan Community. 
OCR is an ex officio
member of this task force.

Page 3:

The second paragraph contains the phrase

referral of the hospital to the U.

Department of Justice for criminal

prosecution.... 
This should be revised to
eliminate reference to " 
criminal
prosecution. 
Remedies under the Hill-Burton 
legislation are limited to specific

performance rather than monetary or criminal

penal ties.
 ... 
Page 3

Page 9:  Reference is made to OCR' s participation in
drafting the regulations formally implemen

ting the COBRA provisions. 
To date, OCR has

not been involved in this effort. 

Should we

be requested to participate in any way in

this drafting process
, I will have OCR staff

available to assist in the accomplishment of

this task.

Page 18: 
Item 2 recommends that R

emergency room

records clearly delineate if a patient was

transferred and from what source; or

transfer leg should be maintained. , a 
This
will effectively aid the OIG, HCFA and OCR in

conducting compliance reviews to ensure that

all patien s transferred from other emergency

tranferred in 
rooms were  stable condition. 
It should be mentioned in this paragraph that

receiving hospital 
the  i8 expected to

maintain the information identified in this

item. We agree that records of patient

transfers must be maintained, and that such

records will aid in the conduct of complaints

and compliance reviews. However
, for this

information to be of maximum benefit, the

records should contain information regarding

the reason for the transfer whenever

possible. 
This information will be valuable 
in identifying the case. of questionable

tranfers and provide the official record

the 81at_nt 
wi th  of the .ending hospital
regard1ng the reason for the transfer. 
This
information may result from telephone

conversations that are to precede the

on 
transfer frem tht hospital to another, or
from records  may accompany the
transferred patient. 
The reference to a Rtransfer 10gR should be

tye 
expanded to identify the 
of information
that is expected to be collected.

Item 3 focuses on outreach to professional

association. We 
believe that outreach ef

forts should extend to communi 
ties and

advocacy groups' 
that reach the potentially
affected individuals. 
As mentioned in item

1, page 17 of this document, Raffected  . . " 
Page 4

parties may be made more likely to report

violations if they are aware of their

rights. . 
Rather than relying on this
awareness to resul 
t from posted notices in
hospitals, we could effect increased public

awareness of rights under COBRA and Hill-

Burton by providing the information directly

to the pUblic through various forms of

contacts, including the mediums of radio

television , and public meetings. 
Some of
OCR' s efforts in this regard are outlined in 
. for 
our comments page 2. 
If further discussion regarding these comments is

required, you may contact me or have your staff contact

Patricia L. Mackey on 245-6118.
 ......, 
DEP:\RT.\H:\T OF HEALTH &. Hl' '\A:\ SERVICES  Health Care 
FInanCing Aar-t"'stra!!c 
Memorandum 
JU 2 
5 /98 
Date 
From  William L. Roper, M.
Administrator 
Subject  OIG Draft Report: "Patient Dumping After COBRA: Assessing the Incidence and
the Perspectives of Health Care Professionals, 
OAI-12-88-00830 
The Inspector General
Offke of the Secretary 
We have reviewed the draft 
he report to be quite informative 
audit and find 
 and
indicative of the diffic:lty of tracking and monitoring patient dumping. 
with the thrust of theOIC's finings and  We agree
recommendations. 
We have taken a number of steps towards implementation of the report' 
recommendations. Our specific comments are attached for your consideration. 
Thank you for the opportuity to comment on this draft report. 
Attachment  eIG Recommendation

Report i n9 of suspected cases of pat i ent 
of participation  dump i n9 shou 1 d be made a cond it ion
(COP) in the Medicare program in order to increase

report i n9. 
HCFA Conents

As the eIG has indicated, HCFA has accepted 
thi s reconvndation. 
however , make this new requirement part of the Provider Agreement We wi 11
Regulations (42 CFR Part 489) instead of the hospital COPs (42 

482). 
Section 489.24(f) of the recently published Notice of ProCpFoRs ePdart

Ru1emaking 
(NPRM), BERC 393-
, Participation in CHAMP 
Hospital Admissions for Veterans, Discharge Rights NotUiSc ea,nd  aCnHdA M
 PVA,
Hospital
Responsibility  for  Emergency Care, would require hospitals which receive 
patients transferred in suspected violation of the patient dumping

requ i rements  the i nci dent to 
and to HCFA, too r rbepoert  subject to terminatiotnh e fMreodm, i tchaer eM eSditactaer es uprrvoegyr aamg.e
ncy
OIG Recommendation 
HCFA and the Office of Civil Rights 

(OCR) should use existing authority

require hospitals to post notices in their emergency rooms informing

pat i ents of thei r ri 
ghts under COBRA and the Hi 11-
indicating a  Burton Act and
local number to call with complaints. 
HCFA Comments

We are confirming with the Office of General Counsel whether HCFA has the

legal authority to require hospitals to post such notices.

OIG Recommndation 
The COBRA regulations should require that 

all emergency room (ER). records
clearly identify all transferred patients to and 
 other ERs. All
pat i ents  be asked upon arri va  from 
shou 1 d  1 at an ER if they have sought
treatment elsewhere.

HCFA Conents

The above requirements are already part of the recordkeeping requirements

of the hospital . 
COPs and the NPRM. 
requires patient medical records to cSoecnttiaoinn  4in8f2o.r2m4(act)io onf o tnh eth heo sppaittiealn tC' OPs
health history. 
Section 489.24(d)(2)(B) of the NPRM would require a
 Page 2

transferring hospital to provide the receiving facility with appropriate

medical records  (or  copies of them) of the examination and treatment 
furnished at the transferring hospital. 
Additionally, in view of the

termination 
, suspension and civil monetary penalty and civil enforcement 
provisions of COBRA and the NPRM
, we expect that hospitals will take

appropriate measures to identify 
all transferred patients in order to

protect themselves from litigation. For 
these reasons, we see no need to

require hospitals to question ER patients upon 
arrival. 
OIG Recommendation 
HCF A and the OCR shou 1 d pursue di rect outreach to profess 
i ona 1
associations to increase awareness of the patient dumping requirements and

to stimulate reporting by health care professionals.

HCF A COrments 
We have already taken action to conduct direct outreach to professional

associ at-ions to increase awareness and stimulate reports of non-compliance

by professionals. Attached 
are copies of letters from Dr. Roper to the

American Hospital Association, the Federation of American Health Systems,

the National Association of Public Hospitals, the 
Amrican Medical
Association and the American Osteopathic Association. 
Please note that
these associations have been requested to inform their members about the

COBRA provisions. Also 
attached is a copy of a letter signed by 
Roper , Richard P. Kusserow Dr.
, the Inspector General
, and Audrey Morton
Director of the Office for Civil Rights, sent directly to the

administrator of each Medicare participating hospital. 
In this letter 
each hospital administrator has been advised that it is 
essential that all
pertinent medical staff, including responsible physicians, 

nurses,
admitting clerks and ambulance attendants (where such services are run out

of the hospital) are reminded about their responsibilities and the

potenti a1 consequences of Yio1 ating the anti-
dumping law. 
The above letters notified the health care provider 
commnity that 
not tolerate cases of neg1  we wi
igence and del iberate malfeasance and requested
their assistance in preventing violations and notifying HCFA of cases that

occur. 
OIG Recomndation 
HCFA should clarify the definitions of "
ization" and lI'
condition" , as the Amrican College of  stabi 1  emergent
Emergency Physicians (ACEP) has
done, in COBRA regu  through proposed 
clarify physicians I arte isonps onsiobr i  1 eg is 1 at ion in order to 
ities under COBRA. Also, 
to the extent

possible, HCFA and OCR should coordinate to assure that the Department

uses a comn 
defini tion of terms when enforcing the patient dumpi
provisions.  " "
Page 3

HCFA Comments 
We believe the definitions of "

to stabilize,  abilized, 
medical condition" contained in COBRA 
 " and "emergency
(section l867(e)) and the NPRM

(section 489.24(b)) are sufficient to identify bonafide emergencies and

establish whether a transfer 

is appropriate. The 
ACEP definitions are too

specific and detailed 
 this purpose. However
the NPRM indicate more fore  laboration is needed
 , if public comments on

definitions in the final rule.  , we will modify the

HCFA has coordinated with OCR in the development of the patient dumping

NPRM. 
HCFA will , of course, follow the same procedure in developing the 
final regulation.

At tachment  .... , ::-
DEPARTME  T OF HEALTH 
&. HL' \\A' SERVICES 
h-=alt  Care F'na  ; A:- " s!-
a!' 
The Ad"n,n'S!ra:::r 
W.sMlniton, DC 2:2:: 
Carol McCarthy, Ph. 
President 
American Hospital Association 
N. Lake Shore Drive
840 
Chicago, DUnois 60611

Dear Dr. McCarthy: 
I am writing to inform you of a letter I have sent 
hospitals participating in  to the administrators of all
Medicare and Medicaid, and to ask your help in sharing its
mesage with your 
members. 
Th letter, 
also signed by Richard Kuserow, the Inspector General, and
Audrey Morton, the Director of the 
Office for Civil Rights, expains the 
anti-dumping" requirements and the consequences of violating them.  statutory
enclosed a copy of the  I have 
letter for your information. 
I know you share my concern that our citizens 
receive emergency treatment
to which they are entitled under law. I hope 

you wal join mein a COpeative
effort so that your members wil be familiar with, and 
comply with, the
requirements of the statute. By working together, we should be able to prevent
dumping and the need to employ the 
rather formidable enforcement 
decribed in the letter.  mechanism
Thank you for your asistance.

e1Y , 
wDlla 
per. M.
Administrator 
Enclosure  DEPART.\\EST OF HEALTH &. HL'.'.. S SERVICES  Healt., Care 
F'r  a"::"i Ad 
r"e Admlnlstratc

JJ 
I 5  W8'''lnl!on  . C, C, 2C2:r
Mr. Michael D. Bromberg 
Executive Director 
Federation of American Health Systems 
Suite If 
1111 19th Street, N. W.

Washington, D.C. 20036 
Dear Mr 
I am writing to inform you of a letter I have sent 
to the administrators of all
hospitals participating in Medicare and Medicaid, and to ask your help in sharing its
message with your members. 
The letter, also signed ' by Richard Kusserow, the Inspetor General, and
Audrey Morton, the Director of the Office for Civil Rights, explains the statutory
anti-dumping" requirements and the consequences of violating them. 
I have
enclosed a copy of the letter for your information. 
I know you share my concern that our citizens receive emergency treatment
to which they are entitled under law. I 
hope you wil join me in a cooperative 
effort so that your members wil be familar with, and comply with, the
requirements of the statute. By working together, we should be able to prevent
dumping and the need to employ the rather formidable enforcement mechanism
described in the letter. 
Thk 
you for your asistance. 
Sincerel y , 
William L. Roper, M.D. 
Administrator 
Enc:osure  .. 
....".. (...  ''''
DEPART,\\E:\T or HEALTH &. HL",1\1A  SERVICES 
;-ieal!;1 Care F,na" 
E: to-=- - S:'a: :

The Ad- st:a 
Wasr1lgtc.;' , DC. 2':::: 
I 5 
1983 
Mr. Lary S. Gage 
President 
National Association of Public Hospitals

Suite 635

1001 Pennsylvania Avenue, N. 
Washington, D.C. 20004

Dear Mr. Gage:

I am writing to inform you of a letter I have sent 
hospitals participating in Medicare and  to the administrators  ot  all
Medicaid, and to ask YOUI help in sharing its
mesage with your members. 
The letter, also signed by Richard Kuserow, the Inspector General, and 
Audrey Morton, the Director 
 ot  the Office  tor  Civil Rights, expains the statutory 
anti-dumping" requirements and the consequences 
 violating them. I have 
ot 
enclosed a copy  ot  the letter for your information. 
I know you share my concern that 
OUl citizens receive emergency treatment
to which they are entitled under law. I hope you will join me in a coperative
effort so that your members will be tamiliar with, and comply with, the 
requirements of the statute. By working together, 
we should be able to prevent

dUlnping and the need to employ the rather formidable enforcement mechanism
described in the letter. 
Thnk you for your asistance. 
WWiam L. Roper, M. 
Administrator 
Enclosure  DEPART.\H.'\T OF HEAL TH &. HL'MA  SER\'CES 
""ea'  :are F'lna":' 
J:-:-
- s
e Ad T"rlistra:cr 
JJ  WashIngton  C. 
I 5  , D.  2:'2::
198 
James H. Sammons, M.

Executive Vice President 
American Medical Association 
535 North Dearborn Street 
Chicago, nUnois 60610

Dear Dr. Sammons: 
a letter I 
I am writing to intorm you 

hospitals participating in Medicarot e and  have sent to the administrators  al1
Medicaid, and to ask your help in sharoitn  g its
mesage with your members. 
The letter, also signed by Richard Kuserow , the Inspector General. and 
Audrey Morton, the Director  the Office tor Civil Rights, explains the statutory
anti-dumping" requirements oat nd the consequences of violating them. 
I have
enclosed a copy 
 ot  the letter tor your intormation. 
I know you share my concern that our 
citizenl receive emergency treatment
to which they are entitled under law. I hope 

you will join me in a coperative
eftort so that your members wil be 
tamilar with, and comply with, the
rdequuimremp einntsg   and toht e tnheee sdt atot uetme.p lBoyy  wthoerk ing together, we should be able to prevent
rather formidable enforcement 
decribed in the letter.  mechanism
Thank you tor your asistance.

WWiam L. Roper, M. 
Administrator 
Enclosure  \\:\:\ 
., , : -
DEP.  RT,'\E:\T Of HEALTH 
&0 Hl'.  S&:R\' 
Heal!"  Care  ',na  ;; .::- - 5:' 
0: :-
'..-r: 
Ti"e A1""  'strat: 
Wasrllngtor:, DC 2:::: 
wU I 5 19 
Joseph W. Stella, D. 
President 
American Osteopathic Association 
1736 Hamilton Street 
Allentown, Pennsylvania 18104

Dear Dr. Stella: 
I am writing to inform you of a letter 
I have sent to the administrators of all
hospitals participating in Medicare and 
message with your members.  Medicaid, and to uk your help in sharing its
The letter, also signed by Richard Kuserow, the Inspector General, 
Audrey Morton, the Director of the  and
Office for Civil Rights, explains the statutory
anti-dumping" requirements and the consequences of
enclosed a copy of the  Violating them. I have 
letter for your information. 
know you share my concern that our 
citizens receive emergency treatment
to which they are entitled under law. 
 hope you will join me in a COperative
effort so that your. members wil be familiar with, and 
comply with, the
requirements of the statute. By 
working together, we should be able to prevent
dumping and the need to employ the 
rather formidable 
described in the letter.  enforcement mechanism
Thank you for your asistance.

o:n 
fj' 
WWi 
Administrator 
Enclosure  . '
'"'' '' '
( E DEP,  RT."'EST OF HEALTH 6;  SERVICES 
"'..4" 
June 15 , 1988

Dear Hospital Administrator:

ThiS letter concerns the 
legal requirement that Medicare

participating hospitals with emergency departments provide emergency

medical treatment to individuals as a condition of their Medicare

provider agreement.

The Consolidated Omnibus Budget Recqnciliation Act of 1985 

added a new section to the  (COBRA) 
Social Security Act, Section 1867--
Responsibilities of Medicare Hospitals 
in Emergency Cases. This
provision establishes a statutory requirement that hospitals with

emergency departments provi 
to all i  de appropri ate medi ca 1 screen i ng exami nat ions
active landbi voi rd.u a 1 s wi th emergency medi ca 1 condi tions and a 11 women in
They may either stabilize the condition or provide a 
medically appropriate transfer to another facility when 

ti ent or  indicated, unless

the pa  representati ve refuses 
the i r 1 ega 1  treatment or transfer.
Although the statute applies to hos 
ls participating in Medicare,

covers both Medi care and non- ati ents. 
Financing Administration  Medi care  The Hea 1 th Care
(HCFA) will terminate hospitals. and the 
Offi
of Inspector General (OIG) may suspend hospi tal s 
and exc 1 ude respons i b 
npeheysd ei dc  ie amnesr fgreonmc yt hcea rMee dii sc avrieo lpartoegdr.a mF uwrhtehne rthi s reQui rement to prov i de 1 e
. the OIG may levy civil

monetary penalties of up to S50.
000 per incident against hospitals and

responsible physicians  statute. 
who have violated the  Individuals
suffering personal harm and medical facilities suffering financial 
loss
can bring civil suit under State law against the offending hospitals.

The Office for Civil Rights 
(OCR) is responSible for enforcing

similar obligations contained in the Hill-
Burton Act' s Comunity Service
requirements. as well as other non-
discrimination statutes. Hospitals
receiving funds under the Hill-
Burton Act of 1946 are required to provide

emergency medi 
ca 1 serv ices based on need. 
The professionalism of a 
hospital and its staff 
is the first and

gnreeatgestl ipgroteecntiocn e and delibfreomr  ateh maraml faenays apnactei ednot  Ocacnc urre. ceive. However , cases of

We will not tolerate
such cases. W. have directed our regional and field offices to enforce

section 1867 and Hill-Burton Act Comunity Service 
requirements
rigorously and also to work with State survey agencies and Peer Review

Organizations. as appropriate. to investigate complaints Quickly and

aggres s i ve I y . 
Clearly our objectives are to prevent patient dumping and to stop 

when it does occur. 
In meeting these objectives. it 
is imperative that

you undertake certain actions to assist the Department of Health and Human
 (')

Page 2 - Hospital Administrator

Services. First, it is essential that you share this information with 
all
pertinent medical staff, including responsible physicians, nurses,

admitting clerks and ambulance attendants where such services are run out

of the hospital , and remind them about their responsibilities and of the

potential consequences of violating the anti-
dumping law. Secondly, it is

imperative that you inform us of any situation where there may be a

suspected violation of the requirements for medical screening, stabilizing

treatment 
, or appropriate transfer so that we can initiate an 
investigation. We have enclosed a list of the HCFA and OCR regional
offi'ces, which will act. as the focal point on all initial complaints, and

a copy of the statute  for  your reference. You are to inform the

appropriate Regional Administrator of HCFA or OCR Regional Manager of any

viol ations as soon as you becom 
aware of them. 
Together we must prevent violations of the 
law. We are grateful to

you and your hospital staff for your 
immediate, continuing, and effective

response to this problem.

Si ncere ly, 
, chard  . Kusserow 
rey  . Morton 
Inspector General  Director 
Office for Civil Rights

L. 
W, um  per
Administra or 
Health Care Financing Administration

Enclosures  /' .. 
-p, 
SOIAL SECURITY Acr-
186ilci 
673 
EXMINATION AND TREATMENT 

FOR EMERGENCY MEDICAL
CONDmONS AND WOMEN IN ACTVE 
SEC.  C.  LABOaJ88
1867. (42 U.  1395dd) 
ca  (a) MEDICAL 
REUIREMEN.  fn the  of a hospital that has a hospitalS ecRmEeErNgIeNnG
cy department, if any individual (whether or not eligible for benefits
under this title) comes to the emergency department and a
made on the individual's behalf for examination or treatmreenute fsotr  ias
medical condition, the hospita must 
medical screning examination within thper ocvaipdaeb ifltoyr  oafn  thaeppropriate
emergency department to determine whether or not  hospital's 
medical condition (within the meaning of subsion  an emergency

to determine if the individual is in acive  (el( 1)) exists
labr 
subsion  (within the meaing
of 
(e)(2)).
(b) NECARY STABILIZING 'ITMEN 
CoNDmONS AND ACTVE LAR.
 FOR EMERGENCY MEDICAL
(1) IN GENERL.-If any individual (whether or not eligible for
th 
benefits under  title) comes to a hospita 
determines that the individual has an  and the hospital
tion or is in active labor, the hospital meumste prrgoevnicdye  medical condi
either-
(A) within the sttT and facilties avaiable at the 
for such further medical examination and such treathmoesnpitt aals, 
may be reuire to stabilze the 
medica condition or to
provide for treatment of the labor, or
(B) for transfer of the 
facilty in accordance with  individual to another medical
(2) RuSAL '1 CONSENT '1 TRsuEbsiAon TMEN. -(Ac). hospital is deemed
to meet the  uirement of paragaph (l)(A) with repe 
individual if the hospital  to an
medical  otTers the individual the further
but thee xaination anda t-reatment desribe in that paragaph
behaf) reifnUdilv tiodu al (or  penon acting on the individual's
consnt to the exaination or trtment.
(31 RESA '1 CONSE '1 T8NSP. -A 
meet the  uirement of paagph (1) hwositphi taI 'ips dee emed to
individua if the hospita  traer  to an

another medca facilty in aoctcTredras ntcoe  with  the individual to
individua (or aa,. penon acting on the siunbsiodn ividual('c)  but the
refus to conlent to the trafer. s behalf)

(c) RESClG TRNSFE 
UNTL PATIEN STABIUZE.
(1) RULE.-If a patient at a hospital has an 
condition with has not ben  emergency medical
stbilzed 
subsion  (within the 
meaning of
tranfer the (pe)a(t4i)e(nBt))  uorn ilse sin  active labor, the hospital may not
1911i
-P,L 560.  8c 
aR, Januarv I. f931c:.31.  lUb8on  , aplicaJ. to contr8 "'tarw 
--sP.s ,PL1 .,t.I o 5L5C 5'.2M 075 .2I2, .'. p91 1o329f01.t2  c"t1oOCC b:Cl.I,. 'i od1"tY11t 'd IoDs noOICt,  mD".flpIn8eJi.bc.lnlli"  y8.  Aw1iuthIW  fI I1 8I"I6,'n:  "1c9d081i6 8.tht.i ADfC t:AO VCto le 0II1.   pI,W i 4"9,i. ntfo9 IoZr1Idl. with

38,  , .n8C".  21. 191. -"y

SOAL SECURITY ACT-f I86ilel 
675 
(B) acting as such an employee or under such a contract.
has profesional responsibility for the 
provision of examina
tions or treatments for the 
individual. or transfers of the
individual. with respet to which the violation occurred. 
(3) CIVIL ENFORCEMENT.
(A) PERSNAL HARN.-Any individual who suffers persnal
harm as a 
diret reult of a participating hospital's violation
of a reuirement of this setion 
may. in a civil action against
the partcipating hospital. obtan thos daages available
for rpeorsnpal rinijuary tunede.r the law of the State in which the 
hospita is locte, and such equitale relief as
LO 
(B) FINANCIAL  TO OTER MEDICAL PACILJ.-Any
medica facilty that 
of a participatig  suffers a financial los as a direc result
this leion may, inh 0a8 pciitvaill' asc vtiioonla atigoani nosft  ath ree puairretimcipeantti nogf
hospita, obta thOl daages available for fmancia los,
under the law of the State in which the hospita is locte,
and such equitable relief as is appropriate. 
(C) LIMITATIONS ON AcrONS. No action may be brought
paraph 
under thi  more than two years after the date of
repe 
the violation with 
(e) DEoNs.-In  to which the acton is brought.
this seion: 
(1) The term "emergency medica condition " mean a medical
condition manifesting itslf by acte symptoms 
saetev emrietyd c(ian actlteundtiio sne vceoruel dp areina)s snuacbhl yt hbte  tehex apbesn cteoo f or efs uuimflftm ciienedn-it 

(A) placing the patient's health in serious jeopardy,
boy 
(B) serious imparment to  functions, or
(C) serious dysfunction of any boily organ or part.
(2) The term "acive labr" mean labr at a time at which-
(A) delivery is imminent,
(B) there is inadequate time to  tl"er
effect sae 
another hOlpita prior to delivery, or 
th(C ) a. trfer may po a threat of the health and saety of
patient or th unborn chd.
(3) The term "pacipatig hospita" means'" hospita that
ba( 4e)nAt)e rTeh ien ttoe ram pr o"tvoid elrt bagilimz"e nmt eunad,e r seon r1e8p66eJ t
with 
emergncy medica  to an
condition, to provide such medica treatment
necry 
of the condition 81 may be 
prilty, tht  to 8Iure, within reasnable
medca 
no material deterioration of the 
tfiaonc ii8t  li!y to l'ult from the tranfer of the individua fcroonmd ia
stiliz" 
(B) the term " means, with repe to an emergency
medica condition, that no material 
tion is litlrye, rw ith renable meddeitcerai oprraotiboani lotfy ,t hteo  croenudilt
from the  of the individua from a faciity.
d(i5h) Tah)e  teorfm a " trasfer" means the movement (includig the
direon of  patient outade a bOlpita's facitiaesu att eth,e
any persn employed by (or afliate or 
lIy 
"'A8 in orna;  "-Id i- "
wi-&Pl LOw.  9ra91ll..r '1l18895 1bo..I,&. Ililaru c1ll8 O UI.  e"afanc iwhue.  1if1 I_U' W  I8nl. obli.... iU8r to
by ',1. 992'2,  HCFA REGIONAL ADM! NI 
STRA TORS 
ReQ i on 

ReQion VI 
John D. Kennedy

Federal Building J. D. Sconce 
Roo  1200 Ma i n Tower  Building 
1 309 
Roo 
sachusetts  2000 
Bos ton . Mas  02203 
(617) 565-1188  Da 11 as . Texas  75202 
(214) 767-6427 
ReQion II 
ReQion VII 
Wi 11 iam Toby 
Gene Hyde

26 Federa 1 Plaza 
Room 3811  New Federal Office Building

New York . New York  10278  R60o1o E ast 12th Street

(212) 264-4488  235
Kansas C1 ty. Mi s sour i 64106 
ReQion III  (816) 374-5233 
Mauri ce Hartman  ReQi on VII I
3535 Market Stret

Francis Ish1 
Room 3100 
Phi ladelphia  Federal Office Building

, Pennsylvania 
19101 
1961 Stout Street 
(215) 596-0324 
Room 574 
ReQion IV  Denver . Colorado 80294 
(303) 844-2111

George R. Ho I 1 and 
ReQ10n IX 
101 Marietta Street 
Su ite 701
Atlanta. Georgia  Robert D. O' Connor 
30312 
(404) 331-2333  100 Van Ness Avenue 
14th Floor

San Franc1 sco, 
ReQi on  California 94102

(415) 556-0254

Chester C. Stroyny

175 West Jackson Boulevard  ReG10n X

Su 1 te A-835 
Chicago, Illinois  Joseph Anderson 
60604 
(312) 353-8507  2901 Th1 rd Avenue 
Ma 11 Stop 502

Seattle, Washington 
98121 
(206) 442-0425
 REGIONAL MANAGERS

OFFICE FOR CIVIL RIGHTS

S. DEPARTMENT OF HEALTH & HUMAN SERVICES
REG I ON I - BOSTON 
REGION VI - DALLAS

Caroline Chang

Room 2403  Da vis Sanders 
Corner of Cambridge & Sudbury  Sui te 1360
J. F.  Sts. 
Kennedy Federa  1200 Main Tower Bldg.
Governmen t Cen ter  1 Bl dg.  Dallas , TX 75202
Boston , MA 02203  Commercial (214) 767-4056
(617) 565-1340  FTS 8-729-4056

FTS - 8-835-1340

REG ION I I - NEW YORK 
REGION VII - KANSAS CITY

John Gomez

Sui te 3312  Loi s V. Carter
Jacob Javitz Bldg. Sui te 248 
26 Federal Plaza  601 East 
12th Street

New York, NY  Kansas City, MO 
10278 64106
Commercial (212) 264-3313  Commercial (816) 426-7277 
FTS - 8-264-3313  FTS 8-867-7277

REG ION I I I 
- PHILADELPHIA 
REGION VIII - DENVER

Pau 1 Cushing
Room 6300  Vada Kyle-Holmes 
Ga teway Bui 1di  Sui te 840
3535 Market Street  1961 Stout Street 
, PA  Denver , CO 
Phi lade Iph ia  19101  80294 
Commercial (215) 596-5831  Commercial (303) 844-2024
FTS 8-564-2024 
FTS - 8-596-1262 
REGION IV - ATLANTA

REG ION  sca
Marie Chretien IX - SAN FRANCI 
Suite 
1502  Virginia Apodaca 
101 Marietta Street Room 322 
Atlanta, GA  50 Uni 
30323  ted Ha tions Plaza
Commercia  San Francisco , CA 
1 (404) 331-5948 94103
FTS 8-242-2779  Commercial (415) 556-8586 
FTS 8-556-8586

REGION V - CHICAGO

REGION X - SEATTLE

Charlot te Irons

33rd Floor  Carmen Rockwell 
300 South Wacker Drive  Room 570 
, IL 
Chicago  2901 3rd Avenue
60606 
Seattle, WA 
Commercia 1 (312) 886-2300  98121 
FTS 8-886-2359  Commercial (206) 442-0473

FTS 8-399-0473  ENDNOTES 
George J. Annas, "Your Money or Your Life: ' Dumping ' Uninsured Patients frm
Hospita Emergency War, 
American Journal of Public Health, 
 76 (Januar 1986),
75. 
David A. Ansell and Roben L. Schiff, "
Patient Dumping: Status, Implications, and
Policy Recommendations, 
Journal of the American Medical  257 (Marh
Associatin, 
1987), 1500.

J. Lawrnce, "Medcal Expens Say Government Could Reduce ' 
Patient Dumping 
The Associated Press,  July 23, 1987.

Michael A. Dowell, "Indigent Access to Hospita Emergency Room Servces, 
Clearn
ghouse Review,  18 (October 1984), 483-499. 
Inortion on States' initiatives in the ara of patient dumping is bas on Dowell, op.
cit., 483-499, and Judith G. Waxan and Sta Dom, " States Take the Lead in Prvent-
ing Patient Dumping , It 
Clearinghouse Review,  Vol. xx, No. , June 1988. 
Caiforna Health and Safety Code, Chapter 1225, s 1317 et seq. 
Health and Safety 
Coe, 1317. 
Mich. Stat. Ann. 14. 15(20715). 
Uta Co An. 216-8-
2(12). 
10.  Wis. Stat. An 146.301. 
11.  Tex. Health and Safety Cod Ann. 4438. 
12.  Unite Stas Gener Accountig Offce, "Health Car: Patient Trasfers frm Emer
gency Rooms to D.C. Gener Hospita " Apri 1987. 
13.  See Amcan College of Emergency Physicians, "Guidelies for Trasfer of Patients,
Anals of Emgency Medcine, December 1985, 
125
14.  See Amercan College of Emergency Physicians, "
Defition of 
Emergency Medcie,
10 Annals of Emergency Medcie 
385, 385-88 (1981). 
15.  U. Hielstein, S. Woolhandler, et al., "Patient Trasfer: Medcal Prtice 
as So
cial Triage,  Amrican Jouml of  74 (1984), 494-97. 
Public Health,  , " 
16.  R.L. Schiff, D.A. Ansell, et al., "Transfers to a Public Hospita: 
A Prospective Study of
467 Patients,  New England Journal  314 (1986), 552-557. 
of Medicine, 
17.  Ansell and Schi provide a more precise estimate in a later 
arcle of $1.04 billion an
nually in total costs shited to the public sector frm 
the private sector due to patient 
trsfers. See Ansell and Schi  Patient Dumping: Status, Implications, and Policy 
Recommendations, 
Journal of American Medical Association,  257 (Mach 1987),
1500-1502. 
18.  Data extrte frm Dowell, "Indigent Access to Hospita Emergency Room Serces, 
Clearnghouse Review 
 (October 1984) and Judith G. Waxan and Sta Dom, " States
Take the Lead in Prventig Patient Dumping,  xx, 
" Clearghouse Review, Vol.  No. 
2, June 1988.