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Newest EMTALA Violation?


One of the issues that sparked the blogfight between Scalpel and Nurse K was the “InQuickER” concept at the Emory Adventist Hospital Emergency Department in Smyrna, Georgia.

According to Emory’s web site, if you pay a $24.99 fee, you can reserve an “appointment” in the emergency department up to 12 hours in advance. You still have to pay for all of your care, but the $25 fee gets you on the “preferred” list. If you aren’t seen within 15 minutes of your appointment time by a physician or a physician’s assistant, you won’t pay for your services.

To “Hold My Place In Line“, all you have to do is enter your symptoms, your name, an e-mail address, and your payment information.

EMTALA requires that emergency departments provide a screening exam and that the screening examination be performed in a nondiscriminatory manner.

If Emory Adventist Hospital is cherry picking patients who have computers with internet connections, who have credit cards, and who can pay a $25 fee to get “In QuickEr”, wouldn’t that be considered just a lit-tle “discriminatory”?

Be interesting to see whether CMS jumps in if a patient who couldn’t afford the $25 copay had to sit longer at the back of the line and experienced a bad outcome.

If we are going to enforce this overbearing law, we have to do so uniformly.

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  1. I think the opposite could apply too. What if a 55-year-old diabetic patient enters “severe indigestion” with a history of GERD as a symptom/history and holds his place in line infarcting at home? The thing makes it sound like you don’t need to be triaged once you arrive other than a set of vitals. Do people read the stuff right away and call you at home to say “get in now” once you enter your symptoms? If you’re “in line” at home, is that like being ignored in the lobby too?

  2. Albert D. Friday, Jr., MD

    Ah, quit your bitchen’… you are just jealous that you didn’t think this brillant idea!

  3. I don’t see the “nondiscriminatory” element of the screening requirement under (a). It merely requires “appropriate.” Off the top of my head, I don’t recall any cases interpreting a nondiscriminatory element to the “appropriate” element.

    The only time “nondiscrimination” shows up in the statute is (g), which refers to transfers to hospitals with “specialized capabilities or facilities.”

    Maybe you know of some case law I don’t. Care to elaborate?

    • Max
      By nondiscriminatory, the implication is that the hospital/Doc is not allowed to ask any financial information before the medical screening exam is done. This is how EMTALA is currently being enforced. To ask for $25 before a medical screening exam is an EMTALA violation, clear and simple.
      This is part of the reason that EMTALA is so onerous. Suppose you go to a hospital and ask “do you take my insurance because I don’t want a big bill?”. We are to answer, according to the JCAHO, HHS and State Inspectors that we cannot answer the question until we have seen you and preformed the appropriate tests to exclude an emergent condition (ie chest pain workup is huge before the emergent condition is ruled out).

      This hospital is in clear violation of EMTALA, assuming it is in the Medicare/Medicaid system. Otherwise, they can ask anything they want.

      If it is in the Medicare/Medicaid program, it’s only a matter of time until this is shut down.

      Worry not, Nurse K.

      • I think you’re confusing different parts of EMTALA and/or the program at issue here.

        There’s nothing in EMTALA’s language that says screening has to be performed on a nondiscriminatory basis. A hospital just has to do an “appropriate” screening. Notably, most courts have held than an “appropriate” screening is not even a screening within the standard of care — if the hospital attempts any “screening” at all, there is no EMTALA liability.

        The program here appears to charge a fee to essentially move yourself forward in the triage; so long as that’s not denying someone else an “appropriate” screening, there’s no violation.

        I find it curious that apparently this “overbearing” law is so onerous that Emory forgot about it entirely when establishing a new payment system. The more reasonable interpretation is that Emory looked at EMTALA, noted it merely requires an “appropriate” screening and does not require equal treatment for screening, and forged ahead with their program.

      • Perhaps the word “nondiscriminatory” is the wrong word. I can only speak to how the various regulatory agencies are enforcing EMTALA, at least in my state, and in my experience. You cannot ask ANY financial questions or ask for ANY payment before a medical screening exam is done, and an emergency condition has been ruled out.

        As to Emory, I suspect they will be receiving a visit from one of the compliance agencies shortly. Perhaps they are trying to say that filling out their form constitutes a medical screening exam, but they would be on very thin ice, if they were in my state.

        As you know, EMTALA states
        “the hospital must provide for an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition (within the meaning of subsection (e)(1) of this section) exists.”

        Clearly, filling out a medical questionnaire online does not meet “appropriate medical screening”. I do not know of many doctors that can determine if a lady is in labor by a online questionnaire. I very much doubt that the enforcement agencies will be sympathetic to Emory if the woman delivers at home waiting for her “appointment” in 4 hours.

  4. @ Igloodoc,

    What happens if I ask whether the ER physicians take my insurance. Over the years with differing insurance plans, I have been, uh, “surprised” to find out that the hospital ER that is listed in my little insurance book employs ER physicians who do not accept said insurance. What gives? How in the world is a PAYING insured patient supposed to navigate this land mine field? I also found that certain pathologists, surgeons, etc. fell under that same bizarre situation.

    Husband had to have an emergent appy. We had an HMO at the time. We went through the primary doc’s office first (even though he was in so much pain, but hey, gotta follow protocol, right?) He sent us to the ER. I actually stopped at home to get the damn book to make sure we were going to the correct “approved” ER, and then I figured it was all good.

    We were SO WRONG. ER doc not on plan, surgeon not on plan, and pathologist not on plan. Needless to say, I was NOT HAPPY and managed to spend hours upon hours on the phone to get it fixed, but so many people don’t look at their EOBs, etc. and “trust” the insurance companies to do the “right thing.”

    • Pink
      In my state, if you are in my ER, we cannot tell you if we take your insurance until we screen you. All hospitals are the same.

      Let me try to explain, as I understand it (and this is not definitive because it is so frakking complicated…).

      In most places, the ER group is an independent contractor to the hospital, and responsible for negotiating its own insurance contracts separate from the hospital. Most ER groups try to take the same insurances as the hospital (and sometimes it is made a contractual requirement by the hospital ). As you can imagine, insurance companies know this and can “lowball” a contract with the ER group. I know of an ER group that was offered 20 cents of the Medicare dollar by a major insurance company to see their patients . So, if we saw the patient we could bill medicare/medicaid $1.00 (and they would pay about 60 cents … another long story). The same patient with the major medical insurance coverage … the ER group could only bill and receive 30 cents. A few to many of these contracts and the ER group goes out of business.

      If that ER group did not have a contract with the large insurance company, the company will reimburse you (personally) more (say 80+ cents) to cover our $1.00 bill sent to you personally. (Presumably they want you as a happy customer, or maybe it is part of your contract with the insurance company … I don’t know why that happens)

      Add to this other variables like the medicare $1.00 (which is currency of healthcare) is going to be reduced this year, EMTALA which forces free care to increasing uninsured, increasing malpractice rates, and so on and it is getting more difficult to make ends meet in the ER, and the primary care.

      (BTW Max … I am led to understand it is federal law that the hospital and ER group cannot combine and negotiate a contract with the insurance company… is this true?)

      • Sorry that should read “the ER group could only bill and receive 20 cents”. My Bad.

      • Not my area so I can’t tell you specifically, though from discussions I’ve had with others in that area, I’d bet your problem is not with federal law, but with the hospital, which sells you out to work its own arrangement with the insurance company.

        Let me add why I suspect that: I have seen few entities behave as viciously as insurance companies trying to keep everything relating to those hospital contracts confidential. Such secrecy also part of why fraud is so rampant in the nexus between health insurers and providers — the market is about as opaque as they come in America, rich with opportunity for exploitation. If you’re not doing the exploiting, you’re being exploited.

  5. There’s squiggle room here in the fact that the ‘appointments’ are made based on the estimated current wait time in the first place. You don’t choose the time you come in, you’re told what time you would’ve had to wait until if you’d come in anyway and if by some chance you come in at that time and miss your ‘appointment’ by more than 15 minutes you don’t pay.

    So in theory the process doesn’t discriminate on the basis of wait times it simply allows you to wait somewhere else and then guarantees you’ll be seen at or near a certain time. Personally if I went to that ED, and I live relatively near (It wouldn’t be my first/nearest choice) I’d probably register online even if I was sitting in the room. That guarantee is pretty valuable IMHO.

    There’s more going on here than the obvious if you ask me. This facility is just outside the ‘real’ Atlanta area, where the stratification of wealth becomes more dramatic. I think this is a test program in a relatively homogeneous county with the goal of setting an example for other facilities to merge towards further in the city.

    If this is an EMTALA violation, and I’m not in the field so I have no strong position on the matter, that is yet another flaw in EMTALA.

  6. I would say if you call the area of the “ER” that sees these scheduled patients something different (like say “Urgent Care”) and staff it separately, it might fly. However, I would never want scheduled visits to the main ER to entice providers to see them before people who are actually sick. Also, I would eviscerate myself from bordom working in such an “Urgent Care” area.

  7. I’d have killed/bribed to work in an urgent care today.

    If anyone had shown up with an “appointment” for allergies today, they’d have sat in the lobby where they belong. I’ve never seen so many sick people in one spot in my life. Like balloon-pumped cath labbeurs, septics, tubed overdoses, florid pulmonary edema. There were like 8 of these at once and no help. Patient after patient after patient. Our doc tubed and lined 4 people in about an hour and a half.

    “The 11:15 seasonal allergy sufferer is here.”

    GO TO HELL. If that person had been bumped ahead of anyone, I’d have called JCAHO, CMS, and whoever else myself.

  8. Hey, if someone makes an appointment in advance for emergency services….doesn’t that demonstrate the lack of an actual emergency? In that case, doesn’t that circumvent/negate EMTALA?

    Just wonderin’

    • Anyone who presents to an emergency ROOM (or the gray-area’d 250 yards from an emergency ROOM) falls under EMTALA. Once the person shows up, they are E-N-T-I-T-L-E-D to a medical screening exam to see if an emergency condition exists whether or not they can pay for said exam. I assume even the uninsured can pay $25 for the appt fee and then not pay the bill for the ER. It would be patently illegal to be uninsured, pay $25, get bumped to the front of the line, then be denied a medical screening exam when they show up to the ER once the staff found out they were uninsured.

  9. If a PCP tried to collect a $25 appointment fee on a Medicare patient, they would be hauled off to jail. No questions asked.

  10. Come on guys! The truth be told the patients using this site are NON-emergent patients. Which EMTALA laws are intended for EMERGENT patients. If you made emergent patients wait for “appointment time” you would have bigger problems than EMTALA.

    This site gives the patient an alternate route to seek ED care. The non-emergent patients are coming to your ED and this site gives you the ability to control that volume.

    Just a thought! Sometimes we make EMTALA more gray than it is.

  11. After looking at their website – it sounds like they are totally bypassing the triage process. Why have someone with a degree and medical training and experience (i.e., the triage nurse) out there evaluating patients when all you really need to do (based on the website at least) is just fill out a short H&P form online? Despite the potential EMTALA violation, I see this as being plain old UNSAFE. UNSAFE, UNSAFE, UNSAFE. I know I certainly wouldn’t want to put my license and livelihood on the line for some computer system. No, I agree wholeheartedly. If you are willing to pay a fee in advance, go to an Urgent Care Center (Doc in the box, whatever you want to call it). Doing this at a physician’s office sounds like a GREAT idea. You aren’t seen within 15 minutes of your scheduled appointment you don’t pay. But an ED? How do these folks sleep at night? They don’t worry about the MI who signed up online with a c/o epigastric pain and hx of GERD not showing up? Do they get to keep the $25 if the pt dies… or more accurately doesn’t show up at the ED at the scheduled time for whatever reason?
    Yes, they do have a section on when to call 911. have you read that yet? Could it be any more bland or generic? There are no specifics, it all boils down to what that lay person thinks of his or her condition. Does this mean that I get to throw all of my experience and training out the window when someone from the waiting room comes up and say’s they or their loved one is sicker or in more of an urgent/emergent situation than the person I triaged ahead of them? Is this now a new standard of care I need to worry about?
    This is just plain not a good idea.

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