I received a recent question on transfers by a mid-level provider and how the co-signature rule would apply:
The regulations and site review guidelines indicate that the mid-level provider (IF THEY ARE AUTHORIZED TO PROVIDE AN MSE IN THE ED by the medical staff bylaws or board authorization) and IF no physician is on duty IN the ED, may effect a transfer and sign the transfer certification AFTER contacting a physician who authorizes the transfer. That physician must then co-sign the transfer certification/transfer form within the time period set under the bylaws or state regulations for the signing of verbal orders (frequently set at 24-48 hours).
Historically, the general assumption had always been that the physician must be a staff member and physically sign the certification. With the growth of ED telemedicine and the use of digital signatures on the EMR, I would now interpret CMS telemed and digital signature regulations and advisories to be read in context with EMTALA to suggest the contact could also be made with a contracted (non-staff) telemedicine PHYSICIAN authorized under policies/procedures/bylaws or with a staff physician to authorize transfers or discharges (depending on the language of the hospital p/p/b). Co-signature could be made be in person or by fax, digital transmission of documents for signature, or remote digital signature to the EMR (RISK TIP: date and time noted next to the written co-signature or digitally by the EMR software.)
The co-signature does not have to appear on the transfer document at the time of transfer but needs to be present when the CMS authorized state surveyors arrive to investigate. The newest regulations (June 2019) require the state to respond within 48 hours of notification for an EMTALA complaint. A prompt complaint could therefore theoretically occur, and state investigators could appear within the same day as a violation — statistically unlikely, but there are anecdotal reports that this has occurred once or twice.
See pp 246-248 EMTALA Field Guide – 4th Edition for more information.