Department of Health and Human Services 
OFFICE OF 
INSPECTOR GENERAL 
THE EMERGENCY MEDICAL 
TREATMENT AND LABOR ACT 
The Enforcement Process 
JANUARY 2001 
OEI-09-98-00221  OFFICE OF INSPECTOR GENERAL 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, is to 
protect the integrity of the Department of Health and Human Services programs as well as the 
health and welfare of beneficiaries served by them.  This statutory mission is carried out through a 
nationwide program of audits, investigations, inspections, sanctions, and fraud alerts.  The 
Inspector General informs the Secretary of program and management problems and recommends 
legislative, regulatory, and operational approaches to correct them. 
Office of Evaluation and Inspections 
The Office of Evaluation and Inspections (OEI) is one of several components of the Office of 
Inspector General.  It conducts short-term management and program evaluations (called 
inspections) that focus on issues of concern to the Department, the Congress, and the public.  The 
inspection reports provide findings and recommendations on the efficiency, vulnerability, and 
effectiveness of departmental programs. 
OEI's San Francisco regional office prepared this report under the direction of Paul A. Gottlober, 
Regional Inspector General.  Principal OEI staff included: 
REGION  HEADQUARTERS 
Cindy Lemesh, Project Leader  Bambi Straw, Program Specialist

Jay Davidson, Lead Analyst

Scott Hutchison, Program Analyst

To obtain copies of this report, please call the San Francisco Regional Office at 415-437-7900. 
Reports are also available on the World Wide Web at our home page address: 
http://www.dhhs.gov/progorg/oei  E X E C U T I V E   S U M M A R Y  
PURPOSE 
The purpose of this inspection was to evaluate the enforcement process for the Emergency 
Medical Treatment and Labor Act (EMTALA). 
BACKGROUND 
Congress passed EMTALA, part of the Consolidated Omnibus Reconciliation Act 
(COBRA) of 1985, in April 1986 to address the problem of patient dumping.  The term 
patient dumping refers to certain situations where hospitals fail to screen, treat, or 
appropriately transfer patients.  According to Section 9121 of COBRA, Medicare-
participating hospitals must provide a medical screening exam to any individual who 
comes to the emergency department and requests examination or treatment for a medical 
condition.  If a hospital determines that an individual has a medical emergency, it must 
then stabilize the condition or provide for an appropriate transfer.  The hospital is 
obligated to provide these services regardless of the individuals ability to pay and without 
delay to inquire about the individuals method of payment or insurance status. 
Congress created a bifurcated enforcement mechanism for EMTALA within the 
Department of Health and Human Services.  The Health Care Financing Administration 
(HCFA) authorizes investigations of dumping complaints by State survey agencies, 
determines if a violation occurred, and, if appropriate, terminates a hospitals provider 
agreement.  The Office of Inspector General (OIG) assesses civil monetary penalties 
against hospitals and physicians and may exclude physicians from the Medicare program 
for repeated or gross and flagrant behavior.  The HCFA may seek the input of the local 
peer review organization (PRO) after the States investigation to help determine whether 
the hospital adequately screened, examined, and treated a patient but must seek PRO input 
in most circumstances before forwarding a case to the OIG if the alleged violation involves 
a question of medical judgment. 
We interviewed staff at HCFA regional offices, State survey agencies, the PROs, and the 
OIG between June and December 1999.  We also reviewed relevant HCFA manuals and 
guidelines as well as law journals.  We obtained logs from HCFA that contain information 
about EMTALA complaints and the outcomes of investigations between Fiscal Years 
1986 and 1998. 
1 
EMTALA  Enforcement  OEI-09-98-00221  FINDINGS 
The EMTALA enforcement process is compromised by long delays and inadequate 
feedback.  Timely processing of EMTALA cases is a longstanding problem.  Delays have 
worsened in recent years, despite a decline in dumping cases.  In addition, HCFA regional 
offices often fail to communicate their decisions to State survey agencies and the PROs. 
The number of EMTALA investigations and their ultimate disposition vary widely 
by HCFA region and year.  Regional offices vary greatly in the number of EMTALA 
investigations that they conduct and the outcomes of those investigations.  For example, 
one region found violations in 22 percent of its investigations while another region found 
violations in 68 percent of its investigations. 
Poor tracking of EMTALA cases impedes oversight.  The HCFAs investigation logs 
contain numerous errors and omit key information about dumping complaints and 
EMTALA investigations.  Although HCFAs central office chose a particular software 
application for tracking EMTALA cases, some regional offices continue to use their own 
methods for data collection. 
Peer review is not always obtained before HCFA considers terminating a hospital 
for medical reasons.  The HCFA instructs States to obtain professional medical review 
during an EMTALA investigation, but this does not always occur.  The HCFA has the 
option of requesting peer review, but this is discretionary even if the State did not obtain 
peer review.  In most cases, the OIG must seek PRO input and may drop a case if the 
PRO finds that medical care was adequate. 
RECOMMENDATIONS 
We recommend that HCFA: 
<<  increase its oversight of regional offices, 
<<  improve collection and access to EMTALA data, 
<<  ensure that peer review occurs for cases involving medical judgment, and 
<<  establish an EMTALA technical advisory group. 
2 
EMTALA  Enforcement  OEI-09-98-00221  AGENCY COMMENTS 
We received written comments from HCFA on the draft report, which are included in the 
appendix.  The HCFA concurred with our recommendations.  The comments describe a 
dedicated HCFA effort to reduce backlogs, improve data collection, and increase 
coordination among the regions.  The HCFA also offered several technical comments, 
which we have incorporated where appropriate. 
3 
EMTALA  Enforcement  OEI-09-98-00221  T A B L E   O F   C O N T E N T S  
PAGE

EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

INTRODUCTION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Purpose  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

FINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  12

Long delays and inadequate feedback . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Case disposition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Poor tracking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Peer review .  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

RECOMMENDATIONS  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  17

APPENDIX

Agency comments  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

4 
EMTALA  Enforcement  OEI-09-98-00221  I N T R O D U C T I O N  
PURPOSE 
The purpose of this inspection was to evaluate the enforcement process for the Emergency 
Medical Treatment and Labor Act (EMTALA). 
BACKGROUND 
Requirements of the Emergency Medical Treatment and Labor Act 
Congress passed EMTALA, part of the Consolidated Omnibus Reconciliation Act 
(COBRA) of 1985, in April 19861 to address the problem of patient dumping.  The term 
patient dumping refers to certain situations where hospitals fail to screen, treat, or 
appropriately transfer patients.  According to Section 9121 of COBRA, Medicare-
participating hospitals must provide a medical screening exam to any individual who 
comes to the emergency department and requests examination or treatment for a medical 
condition.  If a hospital determines that an individual has an emergency medical condition,2 
it must then stabilize the condition or provide for an appropriate transfer.  The hospital is 
obligated to provide these services regardless of the individuals ability to pay and without 
delay to inquire about the individuals method of payment or insurance status.  Hospitals 
may transfer unstable patients only if a physician determines that the benefits of the 
transfer outweigh the risks or if requested by a patient who has been informed of both the 
hospitals EMTALA obligations and the risks of transfer.  Hospitals with specialized care 
facilities, such as burn units, must, within their capacity, accept requests for appropriate 
transfers of patients who require such specialized care.  The following diagram illustrates 
the basic EMTALA requirements: 
1EMTALA became effective on August 1, 1986. 
2Emergency medical condition is defined by law as a medical condition manifesting itself by acute symptoms 
of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably 
be expected to result in (i) placing the health of the individual (or, with respect to a pregnant woman, the health of 
the woman or her unborn child) in serious jeopardy; (ii) serious impairment to bodily functions; or 
(iii) serious dysfunction of any bodily organ or part . . . 
5 
EMTALA  Enforcement  OEI-09-98-00221  Figure 1: Basic EMTALA Requirements 
Emergency room patients must receive a 
medical screening exam without delay 
to determine if they have an emergency 
medical condition. 
Patient has an  Patient does not 
emergency medical  have an emergency 
condition.  medical condition. 
Hospital  Hospital cannot stabilize 
stabilizes  patient and provides an 
patient.  appropriate transfer. 
Hospital has fulfilled basic EMTALA requirements. 
The specific requirements of EMTALA are incorporated in each hospitals Medicare 
provider agreement.  The Health Care Financing Administration (HCFA) requires that in 
addition to providing a medical screening examination and necessary stabilizing treatment 
and appropriate transfers (i.e., the statutory requirements), hospitals must post signs, 
maintain a central log, an on-call roster and patient transfer records, and report EMTALA 
violations to HCFA or the State survey agency.  All such obligations are considered equal, 
and failure to meet any of them constitutes a breach of the Medicare provider agreement 
and possible basis for termination.  Hospitals also may be subject to civil monetary 
penalties of up to $50,000 per violation ($25,000 for hospitals with fewer than 100 beds) 
and civil action.  Physicians who negligently violate EMTALA also are subject to civil 
monetary penalties and, for repeated or gross and flagrant violations, exclusion from 
Medicare. 
Enforcement Mechanisms and Trends 
The HCFA and the Office of Inspector General (OIG) are responsible for enforcing 
EMTALA (see Figure 2 for more information on the EMTALA enforcement process). 
The HCFA authorizes investigations of dumping complaints by State survey agencies, 
determines if a violation occurred, and, if appropriate, terminates a hospitals provider 
6 
EMTALA  Enforcement  OEI-09-98-00221  Figure 2: EMTALA Enforcement Process
Complaint received by . . .
State survey agency (SA) HCFA Regional Office (RO)
Complaint not authorized  RO authorizes SA to investigate the complaint.
for investigation.
SA goes to the hospital, unannounced, and begins the investigation.  
KEY SA holds an entrance conference with the hospital, examines the 
complaint case and a sample of other emergency department 
records, interviews hospital staff, and conducts an exit conference.  
= actions potentially  SA must conduct the investigation within 5 working days of 
affecting Medicare  authorization.
certification
SA must report to RO 10-15 working days after investigation.
= actions potentially 
leading to Civil 
RO has the option to 
Monetary Penalties Based on SAsreport, RO decides  use the peer review 
if EMTALA was violated. organization (PRO)  
for a 5-day review.
EMTALA was not violated and  EMTALA was not violated, but  EMTALA was violated.  
no past violation was found. a past violation was found. (See Figure 4 for 
possible actions.)
Termination date set.
RO notifies the HHS Office of  For medical issues, RO  SA is directed to re-
Inspector General (OIG) and the  forwards the medical records to  survey the facility prior 
Office of Civil Rights that the  PRO for 60-day review. to termination date.
hospital violated EMTALA.
PRO sends the results to OIG. Hospital in 
compliance
Hospital out of 
compliance 
OIG decides not to pursue CMP  OIG has 6 years from the date  Provider agreement 
against the hospital and closes  of the violation to pursue CMP.
terminated
the case.
agreement.  Within the OIG, the Office of Counsel to the Inspector General assesses civil
monetary penalties against hospitals and physicians and may exclude physicians from the
Medicare program.  The HCFA may seek the input of the local peer review organization
7
EMTALA   Enforcement                                                                                                                                                          OEI-09-98-00221 (PRO) after the investigation, when HCFA must decide whether a violation occurred. 
However, by law HCFA must seek PRO input before it forwards a case to OIG which 
requires a medical judgement of a hospitals or physicians liability.3 
State survey agencies perform unannounced, on-site investigations of hospitals and 
forward the results to the regional office.  The purpose of these investigations is to 
determine whether a violation occurred, to assess whether the violation endangers patient 
health and safety, to identify any patterns of violations at the facility, and to assess whether 
the hospital has policies and procedures that implement EMTALAs provisions. 
The number of EMTALA investigations, averaging 400 a year between Fiscal Years 1994 
and 1998, is very small compared to the number of emergency department visits in the 
United States, which totaled approximately 97 million in 1999.  In general, less than 50 
percent of investigations confirm a dumping violation (see Figure 3). 
Figure 3 
Hospitals cited for dumping violations rarely lose their provider agreements.  Since 1986, 
HCFA has terminated 13 hospitals from Medicare due to EMTALA violations.  Only one 
of these terminations occurred after 1993, and it was voluntary.  In practice, HCFA does 
not terminate a hospitals provider agreement if the hospital takes corrective action to 
prevent future violations. 
Civil monetary penalties are relatively uncommon.  The OIG closes more than half of the 
cases it reviews.  To date, the OIG has processed 677 dumping cases; it has declined 
3The OIG can impose a civil monetary penalty without PRO review [i]f a delay would jeopardize the health or 
safety of individuals or when there was no screening examination. . . 42 C.F.R.  489.24 (g)(3) 
8 
EMTALA  Enforcement  OEI-09-98-00221  353 cases and settled 226 (decisions in the remaining cases are pending).  The number of

civil monetary penalties assessed by OIG has increased dramatically in recent years, from a

total of 79 settlements in Fiscal Years 1987 to 1997 to 61 settlements and judgments in

1999 alone.  The increased activity reflects additional OIG staffing that resulted in the

elimination of a backlog of cases rather than a surge in dumping complaints and confirmed

violations (the statute of limitations for assessing civil monetary penalties is

6 years from the date of violation).

Recent Policy Developments 
Implementation of EMTALA has evolved over the years due in part to a lengthy delay 
before final regulations were issued and growing concerns about the impact of managed 
care on access to emergency department services.  In addition, issues continue to arise 
over the application of EMTALA to different hospital departments and operations. 
In 1996, HCFA convened a work group composed of representatives of professional 
organizations and regulatory agencies to address enforcement issues as well as the 
definition of key terms in the law and the impact of managed care.  The work groups 
objective was to produce consensus recommendations for clarifications or changes to the 
statute, regulation, or HCFAs interpretive guidelines (enforcement procedures), with 
emphasis on changes that could be implemented quickly without legislative action or a 
formal rulemaking process.4  The work group formed subgroups to address definitions, 
the enforcement process, and the relationship between EMTALA and managed care.  The 
group submitted its recommendations in January 1997.  The HCFA adopted some of these 
changes when it developed new guidelines for HCFA regional offices and State surveyors. 
These guidelines became effective in July 1998. 
In 1998, HCFA also issued new instructions to State surveyors about the types of 
violations that warranted a 23-day rather than a 90-day termination process.  Before 1998, 
HCFA treated almost all EMTALA violations as potential threats to patient health and 
safety that warranted a 23-day termination process.  The new guidelines distinguished 
between violations that pose an immediate threat to patient health and safety that would 
trigger  23-day termination and those violations that do not affect health and safety and 
would justify a 90-day termination schedule (see Figure 4 on the following page).  For 
example, violations involving a failure to complete required paperwork do not pose a 
threat to health and safety and therefore warrant a 90-day process. 
In November 1999, HCFA and OIG published a Special Advisory Bulletin that 
recommended a number of best practices designed to help hospitals comply with 
EMTALA in a managed care environment where health plans may require hospitals to 
obtain prior authorization for emergency services.  The Bulletin recommended that 
hospitals not seek such authorization but acknowledged that HCFA and OIG have no 
4Joan M. Stieber and Linda J. Spar, EMTALA in the 90s  Enforcement Challenges, Health Matrix: 
Journal of Law-Medicine, Volume 8, Number 1, Winter 1998, pp. 65-66. 
9 
EMTALA  Enforcement  OEI-09-98-00221  authority to require health plans to pay for the screening and stabilizing treatment that 
hospitals are obligated to provide under EMTALA. 
Figure 4: EMTALA Determination and HCFA Actions 
Regional Office  Regional Office Action  Hospital Action 
Determination 
Hospital is in compliance  No action  No action 
No past violation 
Hospital is in compliance  Past violation is referred to OIG  No action 
Past violation  for consideration of possible civil 
monetary penalties 
Hospital is not in compliance  RO begins termination procedures  Hospital has 90 days to develop 
Violation does not pose an  and refers the case to OIG for  and implement a corrective 
immediate and serious threat to  consideration of possible civil  action plan to cease termination 
patient health and safety  monetary penalties  procedures5 
Hospital is not in compliance  RO begins termination procedures  Hospital has 23 days to develop 
Violation poses an immediate  and refers the case to OIG for  and implement a corrective 
and serious threat to patient  consideration of possible civil  action plan to cease termination 
health and safety  monetary penalties and to the  procedures4 
Office for Civil Rights for 
possible action under Hill-Burton 
Previous Office of Inspector General Studies on EMTALA 
In 1988, shortly after Congress enacted EMTALA, the OIG issued two reports on the 
new law.  The first report assessed whether hospital records provided enough information 
to determine the incidence of patient dumping.  The study concluded that reviewing these 
records alone was inconclusive.  The second report assessed the complaint and 
investigation process for dumping cases and found that the process was still evolving, 
coordination among different components needed improvement, and resolution of 
dumping complaints was time-consuming.  In 1995, the Office of Inspector General issued 
a third report on enforcement of EMTALA and focused on HCFA.  Although the report 
concluded that the investigation process was generally effective, it highlighted 
inconsistency among the regional offices with respect to their procedures and compliance 
with HCFA guidelines. 
5If the hospital does not implement a corrective action plan within 21 days (in the case of a 23-day termination) 
or 75 days (in the case of a 90-day termination), the regional office notifies the public of the hospitals pending 
termination through the most expeditious means available (e.g., newspaper, television, or radio). 
10 
EMTALA  Enforcement  OEI-09-98-00221  METHODOLOGY 
We interviewed staff at four HCFA regional offices, eight State survey agencies, five 
PROs, and the OIG between June and December 1999.  We visited HCFA regional offices 
in San Francisco, Dallas, New York, and Atlanta.  We chose these regions because they 
have jurisdiction over half the nations hospitals, and they have historically processed a 
large number of EMTALA cases.6  We also reviewed some actual EMTALA cases.  In 
each region, we visited two State survey agencies and interviewed surveyors and 
managers.  We also interviewed staff from the PROs in the four HCFA regions.  We used 
standardized discussion guides for all interviews. 
In addition to interviews with Federal and State staff, we interviewed emergency 
department nurses and physicians as well as health care attorneys.  We conducted a mail 
survey of emergency department staff and telephone interviews with more than 
100 emergency department managers nationwide for a separate study on awareness and 
impact of EMTALA.  During the telephone interviews, we asked managers about the 
impact of EMTALA and their experiences with EMTALA investigations.  The companion 
report entitled The Emergency Medical Treatment and Labor Act: A Survey of 
Emergency Department Staff (OEI-09-98-00220), discusses the results of our mail survey 
and interviews with emergency department staff. 
We reviewed relevant HCFA manuals and guidelines as well as law journals.  We also 
obtained logs from HCFA that contain information about EMTALA complaints and the 
outcomes of investigations between Fiscal Years 1986 and 1998. 
6These four regions accounted for 65 percent of all EMTALA investigations between Fiscal Years 1994 and 
1998 (1,330 out of 2,036). 
11 
EMTALA  Enforcement  OEI-09-98-00221  F I N D I N G S  
The EMTALA enforcement process is compromised by long 
delays and inadequate feedback 
The HCFA requires State survey agencies to complete investigations within 5 working

days of authorization and submit their reports 10 to 15 working days after the

investigation is complete.  These investigations are labor-intensive and require surveyors

to review a large volume of documents, including a log of emergency department cases for

the past 6 to 12 months, policy manuals, minutes from medical staff meetings for the past

6 to 12 months, credential files, and quality assurance minutes.  In addition, State staff

must review 20 to 50 medical records for emergency department patients.  We found that

State agencies generally meet the mandatory time frames.

Long delays.  Although strict time frames apply to State survey agencies that investigate

complaints of patient dumping, HCFA itself is not subject to any.  Hospitals may wait a

long time to find out the outcome of an investigation and could be subject to a fast-track

termination for an incident that occurred months or years before.  Long delays in

reviewing and deciding cases defeat the purpose of the 23-day termination process, which

is to address immediate threats to patient health and safety.

The logs that we obtained from HCFA central office confirm that timely processing of

cases is a longstanding problem (see Figure 5).  Between 1994 and 1998, the period

reflected in the logs, regional offices took an average of 65 days after the States

investigation to determine if a violation occurred.  Seven of the 10 HCFA regional offices

sometimes took as long as a year or more to decide whether a hospital violated EMTALA. 

Many cases in the logs were marked as pending, despite the fact that the original

complaint often was received years before.  For example, the 1998 logs show

20 cases dating from 1996 as decision pending.

Three State survey agencies that we visited expressed concern about long processing

times in HCFA regional offices.  Staff in one State told us that in some cases 2 years or

more elapse before the hospital finds out its status.  We heard similar concerns from

emergency department administrators.  Three administrators whom we interviewed told us

that their hospitals had been investigated a year or more earlier, but they were still unsure

of the outcomes.  In one case, the hospital was not cited until 4 years after the

investigation had occurred.  [The investigation] loses punch if it takes too long, said one

emergency department director, [because] the staff in question leave.  Staff in HCFA

regional offices acknowledged that they have a backlog of cases.

12 
EMTALA  Enforcement  OEI-09-98-00221  Figure 5 
Inadequate feedback.  State survey agencies, PROs, and hospitals repeatedly complained 
about lack of feedback from HCFA about the outcome of EMTALA cases.  State agencies 
and the PROs, which review material related to alleged dumping violations, rarely learn 
the outcome of the cases they review.  The survey agencies are particularly interested in 
the outcome, because they also license hospitals for the State. 
The number of EMTALA investigations and their ultimate 
disposition vary widely by HCFA region and year 
The volume of investigations within regions occasionally shifts sharply by year, and we 
identified no reason for these swings.  In 1994, for example, one of the largest HCFA 
regions handled 119 EMTALA cases, the second highest total nationally.  The workload 
has since dropped precipitously, and in 1998 the same region handled only three 
EMTALA cases.  Another region logged 42 cases in 1996 and only 7 in 1998. 
Conversely, 7 of the 10 regional offices have seen a rise in their EMTALA caseloads since 
1994.  One regions caseload climbed from 18 cases in 1994 to 74 cases in 1998.  Another 
regions caseload jumped from 13 cases in 1994 to 48 in 1998. 
This inconsistency may mean that hospitals have a higher or lower chance of being 
investigated, depending in large part on their location (see Figure 6).  Nationally, we 
identified 1 investigation for every 15 hospitals between Fiscal Years 1994 and 1998.  In 
one region, however, there was one EMTALA investigation for every eight hospitals in 
the region during the same period.  At the other extreme, the average was 1 investigation 
for every 40 hospitals in another region.  These variations may, in part, be explained by 
staffing differences, regional priorities, or the fact that some regional offices are more 
13 
EMTALA  Enforcement  OEI-09-98-00221  aggressive about screening complaints before they authorize State survey agencies to
conduct investigations.
Figure 6
The percentage of investigations that confirm a dumping violation varies greatly by region
(see Figure 7).  Nationally, 40 percent of investigations substantiated a violation between
Fiscal Years 1994 and 1998.  One region, however, found violations in
22 percent of its investigations while another region found violations in 68 percent of its
investigations.
Figure 7
14
EMTALA   Enforcement                                                                                                                                                          OEI-09-98-00221 In 1997, the Enforcement Process and Procedures Subgroup of the EMTALA Work 
Group noted that there was substantial inconsistencies from state agency to state agency 
and from region to region, in both understanding of the guidelines and in the application of 
the guidelines and law at the respective levels.  To address these inconsistencies, the 
subgroup recommended that HCFA consolidate all rules, regulations, and guidelines for 
State survey agencies and HCFA regional offices in a single manual. 
Poor tracking of EMTALA cases impedes oversight 
Data collection for EMTALA cases has historically been inconsistent and incomplete.  We 
requested investigation logs from HCFA central office in November 1998 and received an 
incomplete set in June 1999.  The documents contained numerous errors and omissions; 
each page was stamped draft, even though the logs reflected activity between 1994 and 
1998.  Key information was absent.  Details were missing concerning the complaints that 
did not result in an investigation, the dates investigations were authorized, and the nature 
of the violations, which can range from technical violations involving a failure to complete 
necessary paperwork to more serious infractions such as failure to perform a medical 
screening exam.  Common errors in the 1998 logs include illogical dates (e.g., dates of 
investigation precede dates of complaint) and incorrect provider numbers. 
Inconsistencies in data collection formats between regions and central office may explain 
the serious and ongoing problems with the logs.  The HCFA central office decided to 
track EMTALA cases in 1995 and requires regions to submit monthly logs, but regional 
offices continue to use their own methods for data collection.  One region uses a different 
software application to track cases and previously tracked cases manually (staff reported 
that they have lost EMTALA files).  Another region developed its own spreadsheet, and 
staff there told us that they had received no guidance from central office about tracking 
cases.  At the time of our interview with this region in June 1999, staff had not submitted 
logs for Fiscal Year 1998.  Another region maintains both electronic and manual logs. 
The historical absence of an accurate, complete central database limits HCFAs ability to 
oversee regional offices.  Specifically, central office cannot track regional workloads and 
address longstanding problems.  Such problems include lengthy delays before regional 
offices determine whether violations occurred, unacceptable backlogs of cases that are 
several years old, and insufficient screening of complaints to assess their legitimacy. 
15 
EMTALA  Enforcement  OEI-09-98-00221  Peer review is not always obtained before HCFA considers 
terminating a hospital for medical reasons 
Although HCFA instructs State survey agencies to conduct professional medical review 
(physician review) during their investigations of alleged dumping violations and provides 
explicit guidelines about what this review should entail, this does not always occur.  In 
1998, HCFA specified that review physicians should be board-certified (if the physician 
being reviewed is board-certified) and should be actively practicing in the same medical 
specialty as the physician treating the patient whose case led to an alleged violation. 
Three State survey agencies out of the eight that we contacted had problems obtaining 
appropriate physician review.  One agency does not employ or contract with any 
physicians, and the remaining two had longstanding problems finding physicians to work 
for the State. 
After the States investigation, regional offices may ask their local PRO to perform a 
5-day review to obtain additional medical expertise.  This review is discretionary, even if 
the State did not obtain professional medical review during its investigation.  Four out of 
the five PROs that we contacted either conduct few or no 5-day reviews. 
In contrast, PRO review is, in nearly all circumstances, mandatory before OIG assesses 
civil monetary penalties, and in many instances the PROs assessment leads OIG to drop a 
case.  In 1990, Congress added a provision to section 1867 of the Social Security Act that 
requires PRO review under certain circumstances before imposition of civil monetary 
penalties.  By statute, the PRO has 60 days to complete this review.  The PRO assesses 
whether a patient had an emergency medical condition that was not stabilized, in addition 
to other medical issues.  According to HCFA guidelines, the PRO must offer to discuss 
the case with the involved physician(s) and hospital(s) and provide them with an 
opportunity to submit additional information.  In 1997, the OIG noted that in some 
regions the PROs disputed HCFAs decision about a case as much as 33 percent of the 
time.7 
7Recommendations, The Enforcement Process and Procedures Subgroup, p. 4. 
16 
EMTALA  Enforcement  OEI-09-98-00221  R E C O M M E N D A T I O N S  
The HCFA central office should increase its oversight of 
regional offices 
The EMTALA enforcement process is marked by considerable inconsistency; this is the

result of the decentralized nature of the process and the sheer number of agencies

involved.

We recommend that HCFA central office: 

<  monitor regions conduct of investigations more closely;

<  consolidate all rules, regulations, and guidelines in a single manual; and

<  establish time frames for regional decisions and intervene if regional offices fail to

meet them. 
The HCFA should continue to improve collection and access 
to EMTALA data 
To facilitate oversight of the regional offices and State survey agencies that play critical 
roles in EMTALA enforcement, HCFA central office should continue to improve data 
collection.  Without aggregate data on complaints and the nature of dumping violations, it 
is impossible to assess the prevalence of patient dumping or whether the violations 
threaten patient health and safety.  Also, PROs and State survey agencies should have 
access to data on EMTALA cases so that they can learn the outcomes. 
The HCFA should ensure that peer review occurs before 
initiating termination actions in cases involving medical 
judgment 
The HCFA expects States to obtain professional medical review when they investigate 
hospitals but does not seek peer review if State agencies fail to follow HCFAs 
instructions.  As a result, hospitals may be subject to termination without the benefit of 
peer review of a physicians actions.  The HCFA should ensure that peer review occurs 
before it seeks termination of a hospitals provider agreement on medical grounds. 
According to HCFA guidelines, appropriate physician review may be performed by 
qualified SA [State agency] physicians or under agreements or contracts with the State 
PRO, the State or local medical association, or other physician groups or individuals. 
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EMTALA  Enforcement  OEI-09-98-00221  The HCFA should establish an EMTALA technical advisory 
group 
The HCFA disbanded the EMTALA Work Group after it submitted its recommendations 
in January 1997.  Questions about EMTALA continue to arise, however, and the health 
care landscape continues to change.  Given the enormous complexity and impact of 
EMTALA on hospitals and physicians, HCFA should consider establishing a technical 
advisory group comprised of representatives from organizations such as the American 
College of Emergency Physicians, American Hospital Association, and the American 
Association of Health Plans as well as State surveyors, patient advocacy groups, and staff 
from the PROs.  Like the original Work Group, the new group could help the agency 
resolve any emerging issues related to implementation of the law.  Current issues include 
specialists who refuse to serve on call panels and inconsistencies between State and 
Federal law governing emergency medical services. 
AGENCY COMMENTS 
We received written comments from HCFA on the draft report, which are included in the 
appendix.  The HCFA concurred with our recommendations.  The comments describe a 
dedicated HCFA effort to reduce backlogs, improve data collection, and increase 
coordination among the regions.  The HCFA also offered several technical comments, 
which we have incorporated where appropriate. 
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EMTALA  Enforcement  OEI-09-98-00221  A P P E N D I X  
Agency Comments

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EMTALA  Enforcement  OEI-09-98-00221  A P P E N D I X  
20 
EMTALA  Enforcement  OEI-09-98-00221  A P P E N D I X  
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EMTALA  Enforcement  OEI-09-98-00221  A P P E N D I X  
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EMTALA  Enforcement  OEI-09-98-00221