Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

JANUARY 2001 

OEI-09-98-00220 

THE EMERGENCY MEDICAL 

TREATMENT AND LABOR ACT 

Survey of Hospital Emergency Departments 
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 
EXECUTIVE SUMMARY 

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, Medicareparticipating 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 individual’s ability to pay and without 

delay to inquire about the individual’s 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 

EMTALA — Emergency Department Survey 1 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 EMTALA’s 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 law’s application to inpatients. 

EMTALA — Emergency Department Survey 2 OEI-09-98-00220 
<

<

Respondents believe that while EMTALA may help protect patients, it also may 

contribute to a hospital’s 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. 

EMTALA — Emergency Department Survey 3 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. 

EMTALA — Emergency Department Survey 4 OEI-09-98-00220 
TABLE OF CONTENTS 

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

EMTALA — Emergency Department Survey 5 OEI-09-98-00220 
INTRODUCTION 

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, Medicareparticipating 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 individual’s ability to pay and without 

delay to inquire about the individual’s 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 

hospital’s 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 

1

EMTALA became effective on August 1, 1986 

2

Emergency 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. . .” 

EMTALA — Emergency Department Survey 6 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 

hospital’s 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 

HCFA’s 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. 

3

The Office of Counsel to the Inspector General performs this function for OIG. 

EMTALA — Emergency Department Survey 7 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 ACEP’s 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 

4

All statistics are from the CDC’s National Hospital Ambulatory Medical Care Survey: 1998 Emergency 

Department Summary, available on CDC’s website at http://www.cdc.gov/nchs/data/ad317.pdf. 

5

For 37 percent of visits, the patient’s HMO status was unknown 

6

We 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. 

7

Frequency totals are current as of May 1998. 

EMTALA — Emergency Department Survey 8 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 hospital’s 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. 

8

For 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. 

9

In instances where fewer than six individuals were employed in a staff category, we sent surveys to all 

staff members of that category. 

EMTALA — Emergency Department Survey 9 OEI-09-98-00220 
FINDINGS 

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 HCFA’s Interpretive Guidelines, published in June 1998, and only 

EMTALA — Emergency Department Survey 10 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 oncall 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. 

EMTALA — Emergency Department Survey 11 OEI-09-98-00220
EMTALA — Emergency Department Survey 12

Figure 4

Figure 5

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. 

patients are not even asked for health insurance information until after a screening exam

has been provided (see Figure 5). 

the screening exam or while it is taking place, but this does not necessarily mean 

OEI-09-98-00220

According to more than 70 percent of registration staff,

Nineteen percent collect insurance information before
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. 

EMTALA — Emergency Department Survey 13 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 

EMTALA’s applicability to patients who are otherwise stable but must be transferred to a 

specialist’s 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, Indiana’s 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 hospital’s 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. 

EMTALA — Emergency Department Survey 14 OEI-09-98-00220 
Respondents believe that while EMTALA may help protect 

patients, it also may contribute to a hospital’s 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. 

EMTALA — Emergency Department Survey 15 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 

State’s 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 nonMedicare 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. 

EMTALA — Emergency Department Survey 16 OEI-09-98-00220 
Hospitals have difficulty staffing on-call panels for some 

specialties 

Common factors contribute to many hospitals' specialist problems 

A hospital’s EMTALA responsibilities Figure 7 

extend to on-call specialists. 

Medicare provider agreements require 

hospitals to maintain a list of on-call 

specialists who can complete medical 

screening exams or provide stabilizing 

treatment for any service for which the 

hospital promotes itself to the 

community. However, many hospitals 

are having difficulty filling on-call 

rosters. Although 63 percent of 

directors believe that specialist 

coverage in their emergency 

Areas for which specialist coverage is 

a problem, in rank order 

1. Neurosurgery 

2. Cardiovascular surgery and cardiology 

3. Pediatrics and subspecialties 

4. Orthopedic surgery 

5. OB/GYN and neonatal services 

6. Neurology 

7. Plastic Surgery 

8. Psychiatry and subspecialties 

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). 

EMTALA — Emergency Department Survey 17 OEI-09-98-00220 
CONCLUSIONS 

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. 

EMTALA — Emergency Department Survey 18 OEI-09-98-00220 
APPENDIX 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 

Estimate 

95% 

Confidence Interval 

Familiarity by staff type (p.9, Figure 2) — Emergency 

physicians 94.1% 89.3% - 98.9% 

Percent of directors who regularly receive EMTALA 

information (p.9) 87.2% 80.6% - 93.8% 

Percent of directors who receive EMTALA 

information directly from HCFA (p.9) 11.4% 5.2% - 17.7% 

Training by staff type — On-call physicians (p.10) 26.2% 16.4% - 36.1% 

Percent of registration staff who say insurance status 

is collected before screening (p.11, Figure 5) 13.3% 6.7% - 19.8% 

Percent of staff who believe an inappropriate transfer 

has taken place (p.12) 4.48% 2.4% - 6.6% 

Percent of registration staff who say authorization is 

sought for stabilizing treatment (p.12) 24.7% 15.9% - 33.5% 

Percent of directors who are unclear on or who 

question some aspect of EMTALA (p.12) 61.9% 52.4% - 71.4% 

Percent of directors who say EMTALA does not 

affect patient care (p.14) 41.4% 31.6% - 51.2% 

Percent of directors who say EMTALA has had a 

negative effect of finances (p.14) 12.0% 5.2% - 18.7% 

Percent of investigated hospitals that changed 

something in response to investigation (pp.14-15) 49.8% 26.4% - 73.2% 

Percent of emergency physicians and nurses who say 

that specialist coverage is a problem at their hospital 

(p.16) 

54.4% 47.8% - 61.0% 

EMTALA — Emergency Department Survey 19 OEI-09-98-00220 
APPENDIX B 

Agency Comments

EMTALA — Emergency Department Survey 20 OEI-09-98-00220 
APPENDIX B 

EMTALA — Emergency Department Survey 21 OEI-09-98-00220 
APPENDIX B 

EMTALA — Emergency Department Survey 22 OEI-09-98-00220 
APPENDIX B 

EMTALA — Emergency Department Survey 23 OEI-09-98-00220