Health care spending continues to increase in the United States.
For example, national health expenditures increased to more than $4 trillion in 2020 ($12,530 per person). And this upward trend shows no signs of slowing.
Similarly, health insurance premiums continue to go up. Indeed, annual family premiums for employer-sponsored health insurance increased four percent for 2021, to an average of $22,221 per family. Of this amount, employers paid roughly 70 percent of premium costs.
In addition, health insurance premiums have grown faster than the growth in wages.
So what does this mean?
Many Americans – 31.2 million people under age 65 – are uninsured.
And approximately 80 million more Americans rely on Medicaid and Children’s Health Insurance Programs (CHIP), which typically pay doctors and hospitals less than Medicare or private health insurance coverage for the same treatment.
Do not let hospitals, doctors, and the health care industry fool you: they like money and profit. Indeed, many health system executives make millions of dollars each year.
Uninsured patients or those with medical benefits coverage (such as Medicare or Medicaid) that pays less than private health insurance may hurt a hospital’s bottom line. For example, one study found that employers and private health insurers pay hospitals more than 200 percent of what Medicare would have paid for the same services at the same facilities.
And this conflict can potentially reduce, or even eliminate, your ability to receive health care if you are uninsured, use Medicare or Medicaid, or owe money to the hospital or affiliated providers for past treatment.
Recognizing the potential for hospitals to refuse to treat uninsured, underinsured, or debtor patients, Congress enacted legislation in the 1980s to prevent health care providers from dumping patients for financial reasons.
This federal law, the Emergency Medical Treatment and Active Labor Act (EMTALA), applies to Medicare-participating hospitals (the overwhelming majority of hospitals outside the Department of Veterans Affairs (VA) system.). And the Centers for Medicare and Medicaid Systems (CMS) publishes rules and regulations interpreting the law.
This article explains when a hospital emergency room or urgent care center must provide medical screening or treatment for an emergency and what legal rights you have under tort law if the hospital violates EMTALA and fails to provide proper screening or stabilizing treatment.
Obtaining the medical care you need is critical in every situation, including when you suffer a work-related injury or get hurt in an auto accident. And I hope you use this information to get the help you need, even if you do not have insurance.
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In 1986, Congress passed the Emergency Medical Treatment and Labor Act (EMTALA).
This federal law was part of the Consolidated Omnibus Budget Reconciliation Act (COBRA).
EMTALA is also called the Patient Anti-Dumping Statute. It requires hospital emergency departments that accept Medicare payments to provide specific treatment to anyone suffering from an emergency medical condition, regardless of citizenship, insurance coverage, or ability to pay.
In other words, EMTALA prevents hospital emergency departments from dumping patients the hospital thinks it will lose money on.
In addition, EMTALA requires hospitals with emergency departments to post signs explaining the rights of persons with emergency medical conditions and women in labor and whether the hospital participates in Medicaid.
The law aims to prevent hospitals from transferring uninsured, Medicare, or Medicaid patients to other facilities without at least providing a screening exam and treatment to stabilize their condition.
EMTALA applies to hospitals that accept payment for services from CMS under Medicare.
Most hospitals accept Medicare and Medicaid, which account for a significant percentage of health care spending. Therefore, EMTALA applies to most hospitals.
EMTALA’s anti-dumping statutes apply to dedicated emergency departments regardless of location (on the main hospital campus or off-site).
A hospital emergency department is subject to EMTALA if it meets one of the following criteria:
In the past few years, it seems that every shopping center (or strip mall parking lot) has added a free-standing urgent care clinic. Examples of these clinics include Patient First, CareNow, BetterNow, Concentra, MedExpress, and American Family Care (AFC).
These urgent care centers allow patients to walk in without an appointment and receive a diagnosis and medical attention. Indeed, many people use these urgent care centers as an alternative to primary care physicians and emergency rooms.
EMTALA applies to urgent care centers in some situations. And Friedrich v. South County Hospital Healthcare provides a framework for when an urgent care center must screen for emergency medical conditions and give treatment to stabilize the patient.
Generally, the critical question is whether the urgent care center is an on-campus or off-campus department of a Medicare-participating hospital.
If the answer is yes, a patient will likely be able to prove that EMTALA applies to the urgent care facility.
Indeed, CMS has stated that most provider-based urgent care centers held to the public as such will be considered dedicated emergency departments under EMTALA.
Further, CMS sees no distinction between “urgent” and “emergency” care. It believes that a person needing emergency care would have difficulty distinguishing between a hospital department that provides care for an “urgent need” and one that offers attention for an “emergency medical condition” need.
We agree.
When you go to the hospital and seek treatment for possible emergency medical conditions, the hospital emergency room must:
EMTALA defines the term “emergency medical condition.”
It means:
In most cases, no.
A significant percentage of emergency room visits are for non-emergency conditions.
However, going to the emergency room for non-life-threatening conditions such as a cold, flu, rash, sinus infection, or other common diagnoses does not make the medical impairment an emergency under EMTALA.
Similarly, under federal law, wellness checks, prenatal care, and follow-up visits with an orthopedic doctor after a back injury or fracture do not qualify as emergency medical conditions.
Therefore, the hospital or free-standing urgent care center may refuse to provide medical attention after screening you.
EMTALA defines the term “to stabilize” for an emergency medical condition.
A hospital stabilizes a patient when it provides such medical treatment as may be necessary to assure, within reasonable medical probability, that transferring the person is unlikely to result in a material deterioration of the condition.
Generally, a patient is stable under EMTALA, therefore ending the emergency department’s legal obligations, if:
The hospital cannot transfer you until your emergency medical condition stabilizes unless:
Yes.
A participating hospital with specialized departments (such as burn units, neonatal intensive care units, or shock-trauma units) cannot refuse to accept an appropriate transfer of a patient with an emergency medical condition requiring specialized care.
You are still liable (responsible) for the cost of emergency medical treatment, even if you do not have health care insurance or the ability to pay.
The hospital (or urgent care facility) may bill you for all medical services rendered.
Indeed, you should not be surprised if the hospital aggressively pursues payment – uncompensated medical attention is a significant percentage of total hospital costs.
However, you may be able to negotiate your hospital bills related to emergency medical treatment and persuade the provider to accept less. Especially if you offer proof of limited financial means.
In addition, the hospital cannot pursue debt collection activities if you have a pending workers comp claim and that occupational injury is why you sought emergency treatment. But make sure you tell the hospital about the case. Then you can resolve the outstanding bills as part of the workers compensation settlement.
Further, you should ask the emergency department to pause collection activities if another driver’s negligence resulted in the need for treatment. Fortunately, many hospitals will wait until the auto accident settlement to seek payment.
No.
A hospital subject to EMTALA cannot delay the provision of a medical screening examination or stabilizing care while determining how you will pay for care or your insurance status.
No, the hospital cannot deny medical attention for an emergency medical condition, even if you owe it money (have an outstanding debt) or it has received a judgment/garnishment against you.
No.
A hospital may not deny treatment or discharge you before stabilizing your condition to make room for a patient with better insurance.
No.
The hospital emergency room must take all reasonable steps to get your written informed consent to refuse the medical screening or treatment to stabilize the emergency medical condition.
However, if you refuse, EMTALA does not require a hospital to provide the examination or treatment.
Similarly, EMTALA does not require the hospital to transfer you to a different facility if you provide written informed consent to refuse such transfer.
Some situations may result in an EMTALA violation and health care provider liability.
Here is a list of emergency department actions that have resulted in liability under EMTALA:
Yes, you have legal options if the hospital emergency room (including its physicians or other medical personnel) violates the provisions of EMTALA.
The federal statute explicitly states that any person who suffers personal harm directly from a hospital’s violation of EMTALA may bring a civil action (lawsuit) against the hospital and obtain those damages for personal injury under the law of the state where the hospital is located.
But you must consider your options under tort law quickly. The statute of limitations for actions against hospitals under EMTALA is two years after the violation date.
Yes.
Both CMS and the Office of the Inspector General (OIG) of the Department of Health and Human Services have the authority to assess civil monetary penalties against emergency department facilities and individual physicians that violate the EMTALA.
Negligent violations of EMTALA may result in:
In addition, any medical facility that suffers financial harm because another hospital violated EMTALA may seek damages against that hospital under the law of the state where the hospital is located.
No.
A poor patient outcome (death or permanent disability) does not mean an EMTALA violation occurred.
Similarly, a positive patient outcome does not mean the hospital or its emergency room physicians complied with EMTALA.
An essential part of our jobs as personal injury attorneys is advocating for medical treatment for our clients.
And this involves making sure you are aware of your right to emergency medical treatment in some situations.
If you have a question about health law or your case, contact us today for a free consultation.
We are here for you.