Department of Health and Human Services 
OFFICE OF 
INSPECTOR GENERAL 
THE EMERGENCY MEDICAL 
TREATMENT AND LABOR ACT 
Survey of Hospital Emergency Departments 
JANUARY 2001 
OEI-09-98-00220  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

Scott Hutchison, Lead Analyst

Rob Gibbons, Program Analyst

Tom Purvis, 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 
To determine whether staff and directors of hospital emergency departments are aware of 
the various provisions of the Emergency Medical Treatment and Labor Act (EMTALA) 
and find out how they believe the Act affects them, their hospitals, and their patients. 
BACKGROUND 
EMTALA 
Congress passed EMTALA, part of the Consolidated Omnibus Reconciliation Act 
(COBRA) of 1985, in April of 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. 
Hospitals' EMTALA responsibilities are incorporated in their Medicare provider 
agreements.  The Health Care Financing Administration (HCFA) requires that hospitals 
comply with the above EMTALA provisions and also:  post signs informing patients of 
their rights to screening and treatment, keep a central log of emergency department visits, 
maintain patient transfer records, and report any inappropriate transfers.  Failure to fulfill 
any of these obligations is considered a breach of the provider agreement and grounds for 
termination.  Medicare provider agreements also require hospitals to maintain a back-up 
call panel for any service for which the hospital promotes itself to the community.  Failure 
of a specialist to report to the emergency department to complete a screening or provide 
stabilizing treatment can result in penalties for both the hospital and specialist. 
Methodology 
We conducted a telephone survey of emergency department directors at more than 
100 randomly-selected hospitals across the nation and a mail survey of emergency 
department and on-call personnel at the same hospitals.  In addition to the surveys, we met 
with representatives from the California chapter of the American College of Emergency 
Physicians and reviewed numerous articles and reports on the subject of 
1 
EMTALA  Emergency Department Survey  OEI-09-98-00220  emergency medicine.  Throughout this study, we protected the identities of our 
respondents. 
FINDINGS 
Emergency department personnel are familiar with EMTALA requirements, but 
many are unaware of recent policy changes 
Emergency department physicians, nurses, registration staff, and on-call specialists

indicate that they are familiar with most of EMTALAs requirements.  Almost all directors

say they regularly receive information about EMTALA, however, only

65 percent were aware of the 1998 Interpretive Guidelines and only 27 percent knew of

the proposed Advisory Bulletin which had been published in the Federal Register.

Training increases EMTALA familiarity for all staff, but on-call specialists and 
staff in high-volume emergency departments are less likely to receive training 
Training increases EMTALA awareness, and nearly two-thirds of emergency physicians, 
nurses, and registration staff receive training.  However, only one-quarter of on-call 
specialists are trained on EMTALA guidelines.  Aside from emergency physicians, staff in 
high-volume emergency departments are less likely to be trained than their counterparts in 
less busy environments. 
Respondents report that hospitals generally comply with EMTALA, but some 
concerns about compliance remain 
Ninety-five percent of staff say their hospital complies with EMTALA.  Registration staff 
say that patients are normally not asked for health insurance information until after medical 
screening.  Some hospitals routinely request authorization for services from health plans, 
but this usually takes place after the exam or treatment is underway or has been 
completed.  A small number of respondents are concerned that some hospital practices 
may violate the law. 
Respondents believe some aspects of EMTALA are unclear or questionable 
Staff need more precise definitions of the terms "emergency medical condition," "medical 
screening exam," and "stability" as well as clarification of certain aspects of patient 
transfers under EMTALA.  Directors and staff sometimes receive conflicting information 
which contributes to their confusion.  Some respondents believe that some current 
EMTALA interpretations and practices exceed legislative intent, especially with regard to 
the laws application to inpatients. 
2 
EMTALA  Emergency Department Survey  OEI-09-98-00220  Respondents believe that while EMTALA may help protect patients, it also may 
contribute to a hospitals administrative and financial problems 
Directors find that EMTALA has generally had a positive effect or no effect on the 
delivery of emergency services.  In contrast to any patient care improvements, respondents 
say that EMTALA has had a negative effect on other aspects of emergency medicine. 
Staff say it creates administrative entanglements, while some directors argue that 
mandating treatment without providing funding aggravates financial difficulties. 
Investigations, many of which do not confirm violations, often prompt changes in 
forms and procedures 
According to HCFA logs, violations were confirmed in less than one-third of 
investigations of the hospitals in our sample.  Despite this, half of the investigated 
hospitals changed some aspect of their emergency department operation in response. 
Managed care creates special problems for hospitals in complying with EMTALA 
According to many directors, private managed care plans reimbursement policies create 
financial stresses, a situation exacerbated by EMTALA.  Prior authorization requirements 
leave many hospitals with a tough choice:  risk an EMTALA violation or forgo 
reimbursement. 
Hospitals have difficulty staffing on-call panels for some specialties 
Medicare provider agreements require hospitals to maintain a specialty call panel for any 
service for which the hospital promotes itself to the community, but many hospitals have 
problems filling on-call rosters.  Shortages most often occur because the community does 
not provide enough patients to support specialists or because certain services are not 
offered at the hospital.  Specialists are increasingly refusing to join back-up panels, a 
critical element of the Nation's health care safety net, because they believe they might not 
be paid. 
CONCLUSIONS 
<<	 Federal Register publication should be supplemented with other methods of 
communicating important policy decisions, such as e-mail and the Internet. 
<<	 The Department should continue to support legislation that would compel 
private managed care plans to reimburse hospitals for EMTALA-related 
services provided to their members, including screening exams which do not 
reveal the presence of an emergency medical condition. 
3 
EMTALA  Emergency Department Survey  OEI-09-98-00220  <<	 Uncompensated care and on-call panels are problems for many hospitals.  These 
are very complex problems which exceed the scope of our study; solutions may 
involve action at the Federal, State, and local levels as well as from private 
entities. 
AGENCY COMMENTS 
We received written comments from HCFA on the draft report (see Appendix B).  The 
HCFA agreed with our conclusions.  The HCFA also offered several technical comments, 
which we have incorporated where appropriate. 
4 
EMTALA  Emergency Department Survey  OEI-09-98-00220  T A B L E   O F   C O N T E N T S  
PAGE

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

INTRODUCTION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Purpose  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

FINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  10

Respondents familiar with EMTALA  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Most staff trained . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Hospital generally comply  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Some policies unclear, others questionable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Care improved, but hospitals burdened . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Investigations result in procedural changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Special problems with managed care  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Specialist coverage an issue  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  18

APPENDIX

Sample confidence intervals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Agency comments  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

5 
EMTALA  Emergency Department Survey  OEI-09-98-00220  I N T R O D U C T I O N  
PURPOSE 
To determine whether staff and directors of hospital emergency departments are aware of 
the various provisions of the Emergency Medical Treatment and Labor Act (EMTALA) 
and find out how they believe the Act affects them, their hospitals, and their patients. 
BACKGROUND 
EMTALA Requirements 
Congress passed EMTALA, part of the Consolidated Omnibus Reconciliation Act 
(COBRA) of 1985, in April of 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 condition2, 
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. 
Hospitals' EMTALA responsibilities are incorporated in their Medicare provider 
agreements.  The Health Care Financing Administration (HCFA) requires that hospitals 
comply with the above EMTALA provisions and also:  provide a medical screening 
examination, provide necessary stabilizing treatment and appropriate transfers, post signs 
informing patients of their rights to screening and treatment, keep a central log of 
emergency department visits, maintain patient transfer records, and report any 
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. . . 
6 
EMTALA  Emergency Department Survey  OEI-09-98-00220  inappropriate transfers.  Failure to fulfill any of these obligations is considered a breach of 
the provider agreement and grounds for termination. 
The EMTALA responsibilities extend to on-call specialists as well as to hospitals and 
emergency department staff.  Medicare provider agreements require hospitals to maintain 
a list of on-call physicians who can complete medical screening exams or provide 
stabilizing treatment for any service for which the hospital promotes itself to the 
community.  Failure of an on-call specialist to report to the emergency department to 
provide stabilizing treatment, unless he or she is unable to do so (e.g., already engaged in 
treating another emergency), can result in penalties for both the hospital and the specialist. 
Enforcement 
Within the Department of Health and Human Services, the Health Care Financing 
Administration (HCFA) and the Office of Inspector General (OIG) are jointly responsible 
for enforcement of EMTALA.  The HCFA authorizes State survey agencies to investigate 
dumping complaints, determines if a violation occurred, and, if appropriate, terminates a 
hospitals provider agreement.  The OIG3 assesses civil monetary penalties against 
hospitals and physicians and may exclude physicians from the Medicare program for gross 
and flagrant or repeated violations of EMTALA.  The OIG may fine a physician or 
hospital up to $50,000 per violation ($25,000 for hospitals with fewer than 100 beds), but 
may impose smaller penalties depending on the situation and the financial state of the 
hospital.  For more information on EMTALA investigations and the EMTALA complaint 
and enforcement process, see the companion report entitled The Emergency Medical 
Treatment and Labor Act: The Enforcement Process (OEI-09-98-00221). 
Previous OIG Work 
Shortly after Congress enacted EMTALA, the Office of Inspector General conducted two 
EMTALA inspections.  The first inspection, whose purpose was to determine if hospital 
records provide enough information to assess the incidence of patient dumping, found that 
(1) medical record review did not provide the necessary information to assess the 
incidence of dumping and (2) hospital staff disagreed about the prevalence of patient 
dumping.  The second inspection, meant to assess the patient dumping complaint and 
investigation process within the Department of Health and Human Services, found that (1) 
the process was still evolving, (2) coordination among different components needed 
improvement, (3) dumping complaints were increasing, and (4) resolution of dumping 
complaints was time consuming.  A third report, issued by OIG in 1995, focused on 
HCFAs  role in the enforcement process.  Although the report concluded that the 
investigation process was generally effective, it highlighted inconsistencies among the 
regional offices with respect to their procedures and compliance with HCFA guidelines. 
3The Office of Counsel to the Inspector General performs this function for OIG. 
7 
EMTALA  Emergency Department Survey  OEI-09-98-00220 Emergency Department Statistics4 
According to the Centers for Disease Control and Prevention, there were 100.4 million 
emergency department visits in 1998.  The expected source of payment for almost 
40 percent of these visits was private insurance, with Medicaid and self-payment following 
at 18 and 15 percent, respectively.  Eighteen percent of visits were from patients in health 
maintenance organizations.5  Triage staff classified 19 percent of visits as emergent (to be 
seen within 15 minutes) and another 31 percent as urgent (to be seen in 15 - 60 minutes). 
Chest pain was the principal complaint for over 40 percent of emergent patients, and their 
average actual wait time was about 20 minutes. 
METHODOLOGY 
We conducted two surveys to achieve the objectives of this study.  The first was a 
telephone survey of emergency department directors at hospitals across the nation.  The 
second was an anonymous mail survey of emergency room and on-call personnel at the 
same hospitals.  In addition to the surveys, we met with national representatives from the 
American College of Emergency Physicians (ACEP) as well as ACEPs California chapter. 
We also reviewed numerous articles and reports on the subject of emergency medicine. 
To create the sample of hospitals used for both surveys, we first used Medicare provider 
certification data to create a universe of Medicare-participating hospitals with emergency 
departments.  We then removed military and psychiatric hospitals from the universe.6  We 
stratified the remaining hospitals into three categories (small, medium, and large) and 
selected a random sample of hospitals from each stratum (see Figure 1). 
Figure 1: Hospital Strata7 
Size  Number of beds  Number in universe  Number selected  Number valid 
Small  1 to 99  3007  62  47 
Medium  100 to 399  2433  47  33 
Large  400 or more  665  48  43 
4All statistics are from the CDCs National Hospital Ambulatory Medical Care Survey: 1998 Emergency 
Department Summary, available on CDCs website at http://www.cdc.gov/nchs/data/ad317.pdf. 
5For 37 percent of visits, the patients HMO status was unknown 
6We removed military hospitals from the universe because they have extremely limited contact with 
private managed care plans. We removed psychiatric hospitals from the universe because of their unique nature 
and because our sample contained too few of them to constitute a statistically valid sub-population. 
7Frequency totals are current as of May 1998. 
8 
EMTALA  Emergency Department Survey  OEI-09-98-00220  In our initial call to the hospital, we verified that the hospital operated an emergency 
department and obtained the name of its director.  We completed telephone interviews 
with directors in 121 of the 123 valid hospitals, meeting our goal of 30 in each stratum. 
Each interview lasted from 15 to 30 minutes. 
We requested lists of emergency physicians, emergency nurses, on-call specialists, and 
registration staff from each valid hospital8; we received the lists from 109.  For each 
hospital, we selected a random sample of six individuals from each category to whom we 
sent the mail survey.9  In total, we received 855 responses to the 2316 surveys 
(37 percent) we mailed, including responses from 36 percent of emergency physicians, 
46 percent of nurses, 32 percent of on-call specialists, and 33 percent of registration staff. 
As shown in the appendix, we received enough valid responses to make national 
projections with acceptable precision.  Our analysis of the mail survey revealed that 
respondents were from slightly smaller hospitals located in slightly less urban areas than 
non-respondents. 
To increase our response rate and to promote candor, we were committed to protecting 
the identities of our respondents throughout the study.  Each hospital was assigned a code 
number which linked the surveys to hospital identification information.  After we finished 
gathering demographic data for each hospital, we deleted the database which contained 
the identification information, leaving no way to link a hospitals code with its name, 
address, or Medicare provider number.  Our coding of the mail surveys prevented the 
connection, at any time, of a respondent to a particular survey. 
8For the remainder of this report, we will refer to these four groups collectively as emergency department 
staff, although emergency and on-call physicians are not always emergency department employees. 
9In instances where fewer than six individuals were employed in a staff category, we sent surveys to all 
staff members of that category. 
9 
EMTALA  Emergency Department Survey  OEI-09-98-00220  F I N D I N G S  
Emergency department personnel are familiar with EMTALA 
requirements, but many are unaware of recent policy 
changes 
The majority of emergency physicians, nurses, registration staff, and on-call specialists 
indicate that they are familiar with most of EMTALA's requirements.  Overall, more than 
80 percent of emergency department staff are familiar with at least 12 of the 
15 EMTALA provisions listed on our survey.  We conclude that staff meeting this 
threshold are highly familiar with EMTALA.  Conversely, only 6 percent of staff are 
familiar with three or fewer requirements.  Emergency physicians and nurses are more 
likely to be familiar with EMTALA than either registration staff or on-call specialists (see 
Figure 2). 
Figure 2 
While more than 90 percent of staff are familiar with the guidelines governing the 
treatment of emergency department patients, fewer are familiar with other aspects of the 
law and regulations.  About 80 percent are aware of requirements to post patients rights 
signs in the emergency room and to maintain a central log of emergency visits.  Fewer 
than 70 percent know that transfer records must be kept for 5 years and that hospitals are 
enjoined from taking retaliatory action against employees who refuse to authorize 
inappropriate transfers or who report violations. 
Although almost all emergency department directors are informed about EMTALA, they 
often are not aware of recent policy changes.  While almost 90 percent of directors 
regularly receive information about EMTALA, it generally comes from other hospital 
staff, professional associations, newsletters, or the Internet.  Only 11 percent receive 
information directly from HCFA.  Perhaps as a consequence, only 65 percent of directors 
are aware of HCFAs Interpretive Guidelines, published in June 1998, and only 
10 
EMTALA  Emergency Department Survey  OEI-09-98-00220  27 percent knew of the proposed EMTALA Advisory Bulletin issued by HCFA and the 
OIG in November 1998.10 
Training increases EMTALA familiarity for all staff, but on-
call specialists and staff in high-volume emergency 
departments are less likely to receive training 
Not surprisingly, training  Figure 3 
has a considerable positive 
effect on EMTALA 
awareness.  On-call 
specialists who are trained 
show the most significant 
increase in familiarity; 
other staff experience 
smaller, but still 
substantial, gains (see 
Figure 3).  One sign of 
increased familiarity is 
that registration staff who 
have received EMTALA 
training are significantly

less likely than those who

have not to request insurance information before a screening exam is provided.

Almost two-thirds of emergency physicians, nurses, and registration staff have received

some training on EMTALA, compared to only about one-quarter of on-call specialists. 

Training usually covers most aspects of EMTALA, though emergency physicians and

nurses are more likely to receive extensive training.  Training received by respondents

usually occurred within 12 months prior to the survey and was conducted by hospital staff. 

Professional associations, such as ACEP, and private consultants also provide training.

Aside from emergency physicians, staff in high-volume emergency departments are less

likely to receive training than their counterparts in less busy environments (see Figure 4 on

the following page).  In high-volume departments, emergency physicians were more likely

than any other staff type to access multiple information sources, which may be why

training for emergency physicians does not follow the same trend as for other staff.

10The Advisory Bulletin became final on November 10, 1999  after our survey was completed. 
11 
EMTALA  Emergency Department Survey  OEI-09-98-00220 Figure 4
Respondents report that hospitals generally comply with
EMTALA, but some concerns about compliance remain
Under EMTALA, a medical screening exam cannot be delayed in order to inquire about an
individual's method of payment.  According to more than 70 percent of registration staff,
patients are not even asked for health insurance information until after a screening exam
has been provided (see Figure 5).  Nineteen percent collect insurance information before
the screening exam or while it is taking place, but this does not necessarily mean 
Figure 5
12
EMTALA  Emergency Department Survey                                                                                                                           OEI-09-98-00220 care has been delayed.  The remainder say that registration depends on the condition of 
the patient.  Cases that appear to be serious are seen immediately, and less critical patients 
may be registered while they wait for qualified personnel to become available to perform a 
medical screening exam. 
Almost 35 percent of registration staff report that they contact health plans for 
authorization of screening exams, and 25 percent seek authorization for stabilizing 
treatment.  Staff11 in hospitals with a high percentage of Medicaid patients are more likely 
to request authorization for stabilizing treatment than those in less Medicaid-dominated 
facilities.  Staff usually request authorization while the screening or treatment is underway 
or after it has been performed. 
While ninety-five percent of staff report that their hospital has implemented policies to 
comply with the above registration and other major EMTALA requirements, a small 
number believe that their hospitals are engaged in practices which may violate the law. 
Four percent believe an inappropriate transfer from their hospital has taken place in the 
past year.  Eight percent, including almost 18 percent in hospitals with a large proportion 
of Medicaid beneficiaries,12 believe that decisions regarding medical screening are at least 
sometimes influenced by a patient's ability to pay.  Furthermore, 15 percent of staff in 
those hospitals that seek authorization for screening exams and 10 percent in those that 
seek authorization for stabilizing treatment believe that screening or treatment is not 
provided when authorization is denied. 
Respondents believe that some aspects of EMTALA are 
unclear or questionable 
Despite an overall high level of familiarity, more than 40 percent of emergency physicians 
and more than 60 percent of directors believe that some parts of the EMTALA law or 
regulations are unclear.  Staff often mention that the terms emergency medical condition 
and medical screening exam need more precise definitions.  Stable for discharge is 
another term that causes some anxiety among respondents.  Since they cannot guarantee 
timely appointments with specialists, emergency physicians worry that EMTALA may 
obligate them to ensure that a patient has appropriate follow-up care outside the 
emergency department.  In addition to concerns about these terms, many staff have 
questions about registration and other hospital procedures in light of EMTALA. 
11On-call specialists responses were not considered for this issue. 
12Medicaid percentage was determined by dividing the number of Medicaid adult and pediatric bed days 
by the total adult and pediatric bed days for each hospital. Data are from facility cost reports beginning in Fiscal 
Year 1997. 
13 
EMTALA  Emergency Department Survey  OEI-09-98-00220  Many specific questions surrounding appropriate transfers surfaced in the two surveys. 
Several respondents were unclear whether EMTALA applied to a transfer of an 
emergency department patient to another building on the same medical campus. 
Conversely, a director at a hospital with buildings on two separate campuses wondered 
how EMTALA applied to transfers between those facilities.  Others questioned 
EMTALAs applicability to patients who are otherwise stable but must be transferred to a 
specialists office or another facility with special equipment in order to complete testing. 
One on-call specialist feared that the exact nature of specialized care may encourage 
transfer, but fear of [an] EMTALA sanction may discourage [it]. 
State law can further complicate the landscape for hospitals within a particular State.  For 
instance, according to one director, Indianas Medicaid regulations stipulate that the 
emergency physician should call the primary care physician before screening, but 
EMTALA mandates a screening without delay.  In Delaware, according to another 
director, any adult candidate for involuntary psychiatric commitment must be transferred 
to the State hospital, but these patients are not defined as stable for transfer under 
EMTALA. 
A number of respondents believe that some current interpretations and practices 
exceed legislative intent 
While respondents generally agree that EMTALA is an important law, many believe that 
the effects of associated regulations exceed the intent of the legislation.  Some directors 
believe that emergency medicine is becoming over-regulated, and that this increased 
regulation is not always in the best interest of the patient.  Others say that assessing civil 
monetary penalties in EMTALA cases where there is a quality of care issue turns the law 
into a federal malpractice statute.  It seems to us that EMTALA has become a catch-all 
to enforce quality of care, instead of just the anti-dumping statute it was originally 
intended to be, summarized one director. 
One particularly controversial question is When does a hospitals EMTALA 
responsibility end?  Some believe that EMTALA covers patients who are admitted to the 
hospital through any department and later develop an emergency medical condition.  Many 
of the respondents to our surveys disagree with this interpretation and believe that such an 
opinion represents a departure from the intent of the law.  For example, one director 
expressed concern that such a view would expose hospitals to EMTALA whenever an 
appropriately discharged patient is readmitted for an exacerbation of the original 
condition.  The Department plans to issue a Notice of Proposed Rulemaking on this issue 
in the near future. 
14 
EMTALA  Emergency Department Survey  OEI-09-98-00220  Respondents believe that while EMTALA may help protect 
patients, it also may contribute to a hospitals administrative 
and financial problems 
EMTALA may have a positive effect on care 
Directors find that EMTALA generally has either a positive effect or no effect on the 
delivery of emergency services.  At 44 percent of emergency departments, directors 
believe EMTALA has improved quality of care, mainly through the patient protections it 
provides.  Forty-one percent, however, say that patient care is not affected.  Many of these 
directors state that their hospital already had provided screening and stabilization services 
to all emergency patients before EMTALA was implemented. 
Other aspects of the emergency department may suffer 
In contrast to any patient care improvements, EMTALA has had a negative effect on other 
aspects of emergency medicine, according to more than 25 percent of directors and almost 
40 percent of staff.  Many staff believe that it creates layers of unnecessary bureaucracy 
and complicates routine procedures.  Some also believe that it promotes overutilization of 
the emergency room, explaining that patients may obtain treatment for non-emergency 
conditions by exploiting hospitals' fear of violating EMTALA.  According to some 
respondents, these are often managed care patients who do not or cannot obtain an office 
visit with their primary care physician. 
Though not specifically asked, 12 percent of directors volunteered that EMTALA has 
contributed to the financial problems that many emergency departments are now facing. 
Mandating medical screening and stabilization of emergency conditions without providing 
a source of funding is one of their major concerns.  Several respondents commented that 
having to provide screening exams for non-emergent patients who lack insurance or 
whose insurance will not pay is especially frustrating. 
Investigations, many of which do not confirm violations, 
often prompt changes in forms and procedures 
According to HCFA logs, since 1986 a total of 73 investigations were conducted at 47 of 
the 123 valid hospitals in our sample.  Twenty of the hospitals were investigated multiple 
times in that period, one of which underwent five separate investigations.  Larger hospitals 
and those with high-volume emergency rooms are more likely to be investigated, which is 
not surprising since they see more patients and have a greater chance of having a 
complaint lodged against them. 
15 
EMTALA  Emergency Department Survey  OEI-09-98-00220  Violations were confirmed in only one-third of investigations, but almost half of the 
investigated hospitals changed some aspect of their emergency department's operation as a 
result.  Typically, hospitals revised old forms, introduced new ones, or amended other 
practices.  A smaller number provided training for staff or revised policies.  For more 
information on investigations, see the companion report. 
Managed care presents special problems for hospitals in 
complying with EMTALA 
Almost 20 percent of directors say that dealing with managed care strains emergency 
department finances, a situation exacerbated by EMTALA.  According to some 
respondents, as well as ACEP and other sources, private managed care organizations deny 
or reduce payment for mandated medical screening exams when the patient is found not to 
have an emergency condition.  Though some directors indicate that prudent layperson 
standards, such as those that exist for Medicare and Medicaid managed care plans, have 
helped secure payment, others suggest that the standards are insufficient to guarantee 
adequate reimbursement.  Indeed, a University of North Carolina analysis of two of that 
States payers found that 76 percent of the emergency visits denied as not a medical 
emergency met the State prudent layperson standard. 
Although the Interpretive Guidelines and the Advisory Bulletin caution hospitals against 
seeking prior authorization, respondents report that many private plans will not pay for 
emergency services that have not been authorized before they are rendered.  This leaves 
hospitals with the difficult choice of calling the health plan before the exam and possibly 
violating EMTALA or waiting until after the exam is provided and risking non-payment. 
In the Advisory Bulletin, HCFA and OIG state that they were unable to resolve [the 
issue] because we do not have the authority under [EMTALA] . . . to regulate non-
Medicare and non-Medicaid managed care plans. 
One approach that has been reported as a way for managed care organizations to address 
emergency services is known as dual staffing.  Dual staffing refers to situations where 
a managed care organization stations its own physicians in a hospital emergency 
departments to screen and treat their enrollees who request emergency services.  The 
Advisory Bulletin states that, while they are not a per se violation, hospitals which employ 
dual staffing arrangements face added burdens in complying with EMTALA.  We found 
that dual staffing is not a widespread practice; only two of the hospitals in our sample have 
dual staffing arrangements.  In fact, most directors we interviewed did not even know the 
meaning of the term. 
16 
EMTALA  Emergency Department Survey  OEI-09-98-00220  Hospitals have difficulty staffing on-call panels for some 
specialties 
Common factors contribute to many hospitals' specialist problems 
Figure 7 
A hospitals EMTALA responsibilities 
extend to on-call specialists. 
Areas for which specialist coverage is 
Medicare provider agreements require 
a problem, in rank order 
hospitals to maintain a list of on-call 
specialists who can complete medical 
1. Neurosurgery 
screening exams or provide stabilizing  2. Cardiovascular surgery and cardiology 
treatment for any service for which the  3. Pediatrics and subspecialties 
hospital promotes itself to the  4. Orthopedic surgery 
community.  However, many hospitals  5. OB/GYN and neonatal services 
6. Neurology 
are having difficulty filling on-call 
7. Plastic Surgery 
rosters.  Although 63 percent of 
8. Psychiatry and subspecialties 
directors believe that specialist 
coverage in their emergency 
department is more than adequate, 54 percent of doctors and nurses say staffing is a 
problem for some specialties.  Figure 7 displays the most commonly mentioned areas of 
concern.  Shortages most often occur because the community in which the hospital is 
located does not provide a sufficient base of patients to support specialists in a particular 
field or because certain services are not offered at the hospital. 
Another aspect of the specialist problem is the refusal of specialists to serve on call panels, 
particularly in States with high managed care penetration or a large proportion of people 
without health insurance.  Only 12 percent of emergency physicians and nurses give 
specialists refusal as a reason for their on-call shortage, but, of these respondents, 63 
percent work in California, Pennsylvania, Texas, or Nevada.  These represent, 
respectively, the States with the highest and third highest rates of HMO penetration and 
uninsured persons among all of the States represented by hospitals in our sample. 
Reports in the national media and research conducted by private organizations suggest 
that financial concerns are at the heart of many specialists reluctance to join call panels. 
Respondents to a survey developed by a task force comprised of members of ACEP, the 
California Medical Association, and the California Health Care Association ranked lack of 
adequate payment under managed care and resentment over not being paid as the 
second and third most important reasons for back-up panel problems.  According to 
ACEP and several news articles, specialists do not wish to participate on call panels as 
they stand a good chance of not being reimbursed for services which they are required to 
provide.13 
13 For more information, see the article "Emergency Department Back-up Panels: A Critical Component 
of the Safety Net Problem" in Defending America's Safety Net (American College of Emergency Physicians, 1999). 
17 
EMTALA  Emergency Department Survey  OEI-09-98-00220  C O N C L U S I O N S  
Communication and Education 
Many emergency department directors are not aware of important changes to Federal 
EMTALA policy.  Since hospitals and physicians face serious penalties for any infractions, 
HCFA and OIG need to ensure that important decisions are communicated to hospitals, 
emergency department directors, and staff in a timely manner.  We found that most 
directors and staff receive EMTALA information from professional associations and 
consultants.  Therefore, HCFA and OIG should distribute information to these groups as 
well and may wish to consult with them to develop effective more outreach methods. 
Direct e-mail notification to hospitals and posting of decisions on websites are just two 
possibilities that could lead to better dissemination of information. 
Managed Care 
The Department should continue to support legislation that would require private 
managed care plans to reimburse hospitals for EMTALA-related services, including 
screening exams which do not reveal the presence of an emergency medical condition. 
This is important because EMTALA requires hospitals to provide screening exams and 
stabilizing treatment, but the Act imposes no requirements on private managed care plans 
to pay for these services.  Although the Advisory Bulletin clearly states that seeking prior 
authorization is improper, HCFA and OIG have no authority to compel private health 
plans to pay for emergency services. 
Uncompensated Care and On-Call Panels 
Lack of compensation for screening and stabilization services to the uninsured is 
increasingly burdensome to hospitals.  In addition, many hospitals are experiencing 
increased difficulty in retaining on-call specialists.  These are very complex problems 
which exceed the scope of our study; solutions may involve action at the Federal, State, 
and local levels as well as from hospitals and other private entities. 
AGENCY COMMENTS 
We received written comments from HCFA on the draft report (see Appendix B).  The 
HCFA agreed with our conclusions.  The HCFA also offered several technical comments, 
which we have incorporated where appropriate. 
18 
EMTALA  Emergency Department Survey  OEI-09-98-00220  A P P E N D I X  A  
Sample Confidence Intervals 
The following table shows point estimates and 95 percent confidence intervals for selected 
statistics and their location in the report. 
Statistic  Point  95% 
Estimate  Confidence Interval 
Familiarity by staff type (p.9, Figure 2)  Emergency 
94.1%  89.3% - 98.9% 
physicians 
Percent of directors who regularly receive EMTALA 
87.2%  80.6% - 93.8% 
information (p.9) 
Percent of directors who receive EMTALA 
11.4%  5.2% - 17.7% 
information directly from HCFA (p.9) 
Training by staff type  On-call physicians (p.10)  26.2%  16.4% - 36.1% 
Percent of registration staff who say insurance status 
13.3%  6.7% - 19.8% 
is collected before screening (p.11, Figure 5) 
Percent of staff who believe an inappropriate transfer 
4.48%  2.4% - 6.6% 
has taken place (p.12) 
Percent of registration staff who say authorization is 
24.7%  15.9% - 33.5% 
sought for stabilizing treatment (p.12) 
Percent of directors who are unclear on or who 
61.9%  52.4% - 71.4% 
question some aspect of EMTALA (p.12) 
Percent of directors who say EMTALA does not 
41.4%  31.6% - 51.2% 
affect patient care (p.14) 
Percent of directors who say EMTALA has had a 
12.0%  5.2% - 18.7% 
negative effect of finances (p.14) 
Percent of investigated hospitals that changed 
49.8%  26.4% - 73.2% 
something in response to investigation (pp.14-15) 
Percent of emergency physicians and nurses who say 
that specialist coverage is a problem at their hospital  54.4%  47.8% - 61.0% 
(p.16) 
19 
EMTALA  Emergency Department Survey  OEI-09-98-00220  A P P E N D I X  B  
Agency Comments

20 
EMTALA  Emergency Department Survey  OEI-09-98-00220  A P P E N D I X  B  
21 
EMTALA  Emergency Department Survey  OEI-09-98-00220  A P P E N D I X  B  
22 
EMTALA  Emergency Department Survey  OEI-09-98-00220  A P P E N D I X  B  
23 
EMTALA  Emergency Department Survey  OEI-09-98-00220