The new healthcare reform law is causing rampant confusion on many levels, and that includes among payors, plans, employers, and hospital personnel similar to the push for HMO’s and Healthcare planning in the 1990’s. Because of the varied issues, CMS has issued a clarification on EMTALA — and as I predicted, EMTALA is not going away.
In a December 13, 2013 bulletin to state enforcement agencies (S&C: 14-06-Hospitals /CAHs), CMS addressed a number of questions and concerns. The make them more easy to digest, I will present them in separate posts.
DOES EMTALA APPLY TO OBAMACARE?
CMS has received questions from providers that suggest third-party health services payors may be proposing or establishing payment-related policies and procedures that could, if adhered to by Medicare-participating hospitals and CAHs, place those facilities and their physicians at risk for noncompliance with EMTALA. Providers submitting questions to CMS have expressed confusion about whether a third party payor’s policies might alter EMTALA compliance requirements, or have asked CMS to intervene where they believe a proposed Medicaid policy would create conflicts with EMTALA.
It is important for all parties to understand that, regardless of the individual’s payment method and/or the ability to pay, a Medicare-participating hospital or CAH must provide the services required under EMTALA, in accordance with 42 CFR 489.20, subsections l, m, q, and r, and 42 CFR 489.24. Furthermore, in the case of Medicaid payor proposals, it is important to be aware that not every proposal under discussion in a State ends up being formally included as an amendment to its State Medicaid plan. Furthermore, CMS will only approve revisions to State Medicaid plans that adhere to applicable Federal regulations, including those governing provision of emergency services. When CMS becomes aware of existing or proposed State Medicaid policies or practices that would create conflict with Federal Medicaid or EMTALA requirements, it takes action to resolve the conflict.
TO SUMMARIZE IN ENGLISH:
Just because your state has a Medicaid waiver or a plan seeks to institute new procedures, don’t think that you are exempt from EMTALA for state programs or payment plans.
HISTORY:
With the advent of HMO’s — especially in California — efforts were made to impose cost cutting rules like triage-out, pre-authorization, reduced payments for non-plan providers, and pre-authorization. The result was that hospitals did what the plans or the state Medicaid offices told them for procedures and ended up getting cited by CMS for EMTALA violations. The plans were not subject to EMTALA, and chose to try to shift the risk to hospitals and healthcare providers. Every few years, a new round of contracts and new CFO’s without EMTALA citation experience produced a new round of EMTALA citations and fines.