Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

JANUARY 2001 

OEI-09-98-00221 

THE EMERGENCY MEDICAL 

TREATMENT AND LABOR ACT 

The Enforcement Process 
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 
EXECUTIVE SUMMARY 

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, 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. 

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 hospital’s 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 State’s 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. 

EMTALA — Enforcement 1 OEI-09-98-00221 
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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 HCFA’s investigation logs 

contain numerous errors and omit key information about dumping complaints and 

EMTALA investigations. Although HCFA’s 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. 

EMTALA — Enforcement 2 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. 

EMTALA — Enforcement 3 OEI-09-98-00221 
TABLE OF CONTENTS 

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

EMTALA — Enforcement 4 OEI-09-98-00221 
INTRODUCTION 

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, 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 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 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. The following diagram illustrates 

the basic EMTALA requirements: 

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 — Enforcement 5 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 

emergency medical 

condition. 

Patient does not 

have an emergency 

medical condition. 

Hospital 

stabilizes 

patient. 

Hospital cannot stabilize 

patient and provides an 

appropriate transfer. 

Hospital has fulfilled basic EMTALA requirements. 

The specific requirements of EMTALA are incorporated in each hospital’s 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 hospital’s provider 

EMTALA — Enforcement 6 OEI-09-98-00221 
Complaint received by . . .

Complaint not authorized 

for investigation.

RO authorizes SA to investigate the complaint.

State survey agency (SA) HCFA Regional Office (RO)

SA goes to the hospital, unannounced, and begins the investigation. 

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. 

SA must conduct the investigation within 5 working days of 

authorization.

SA must report to RO 10-15 working days after investigation.

Based on SA’s report, RO decides 

if EMTALA was violated.

RO has the option to 

use the peer review 

organization (PRO) 

for a 5-day review.

EMTALA was not violated and 

no past violation was found.

EMTALA was not violated, but 

a past violation was found.

EMTALA was violated. 

(See Figure 4 for 

possible actions.)

Termination date set.

SA is directed to resurvey the facility prior 

to termination date.

Hospital in 

compliance

Hospital out of 

compliance –

Provider agreement 

terminated

RO notifies the HHS Office of 

Inspector General (OIG) and the 

Office of Civil Rights that the 

hospital violated EMTALA.

For medical issues, RO 

forwards the medical records to 

PRO for 60-day review.

PRO sends the results to OIG.

OIG decides not to pursue CMP 

against the hospital and closes 

the case.

OIG has 6 years from the date 

of the violation to pursue CMP.

= actions potentially 

affecting Medicare 

certification

= actions potentially 

leading to Civil 

Monetary Penalties

KEY

EMTALA — 7

Figure 2: EMTALA Enforcement Process

agreement. 

monetary penalties against hospitals and physicians and may exclude physicians from the

Medicare program. 

Enforcement OEI-09-98-00221

Within the OIG, the Office of Counsel to the Inspector General assesses civil

The HCFA may seek the input of the local peer review organization
(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 hospital’s or physician’s 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 EMTALA’s 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 hospital’s 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 

3

The 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) 

EMTALA — Enforcement 8 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 group’s 

objective “was to produce consensus recommendations for clarifications or changes to the 

statute, regulation, or HCFA’s 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 

4

Joan 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. 

EMTALA — Enforcement 9 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 

Determination 

Regional Office Action Hospital Action 

Hospital is in compliance— 

No past violation 

No action No action 

Hospital is in compliance— 

Past violation 

Past violation is referred to OIG 

for consideration of possible civil 

monetary penalties 

No action 

Hospital is not in compliance— 

Violation does not pose an 

immediate and serious threat to 

patient health and safety 

RO begins termination procedures 

and refers the case to OIG for 

consideration of possible civil 

monetary penalties 

Hospital has 90 days to develop 

and implement a corrective 

action plan to cease termination 

procedures5 

Hospital is not in compliance— 

Violation poses an immediate 

and serious threat to patient 

health and safety 

RO begins termination procedures 

and refers the case to OIG for 

consideration of possible civil 

monetary penalties and to the 

Office for Civil Rights for 

possible action under Hill-Burton 

Hospital has 23 days to develop 

and implement a corrective 

action plan to cease termination 

procedures4 

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. 

5

If 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 hospital’s pending 

termination through “the most expeditious means available” (e.g., newspaper, television, or radio). 

EMTALA — Enforcement 10 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 nation’s 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. 

6

These four regions accounted for 65 percent of all EMTALA investigations between Fiscal Years 1994 and 

1998 (1,330 out of 2,036). 

EMTALA — Enforcement 11 OEI-09-98-00221 
FINDINGS 

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 State’s

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.

EMTALA — Enforcement 12 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 region’s caseload climbed from 18 cases in 1994 to 74 cases in 1998. Another 

region’s 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 

EMTALA — Enforcement 13 OEI-09-98-00221 
EMTALA — 14

Figure 6

Figure 7

aggressive about screening complaints before they authorize State survey agencies to

conduct investigations.

The percentage of investigations that confirm a dumping violation varies greatly by region

(see Figure 7). 

Fiscal Years 1994 and 1998. 

22 percent of its investigations while another region found violations in 68 percent of its

investigations.

Enforcement OEI-09-98-00221

Nationally, 40 percent of investigations substantiated a violation between

One region, however, found violations in
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 HCFA’s 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. 

EMTALA — Enforcement 15 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 State’s 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 PRO’s 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 HCFA’s decision about a case as much as 33 percent of the 

time.7 

7

Recommendations, The Enforcement Process and Procedures Subgroup, p. 4. 

EMTALA — Enforcement 16 OEI-09-98-00221 
RECOMMENDATIONS 

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 HCFA’s 

instructions. As a result, hospitals may be subject to termination without the benefit of 

peer review of a physician’s actions. The HCFA should ensure that peer review occurs 

before it seeks termination of a hospital’s 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.” 

EMTALA — Enforcement 17 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. 

EMTALA — Enforcement 18 OEI-09-98-00221 
APPENDIX 

Agency Comments

EMTALA — Enforcement 19 OEI-09-98-00221 
APPENDIX 

EMTALA — Enforcement 20 OEI-09-98-00221 
APPENDIX 

EMTALA — Enforcement 21 OEI-09-98-00221 
APPENDIX 

EMTALA — Enforcement 22 OEI-09-98-00221