Are your plans requiring pre-authorization for admission or transfer following the MSE? Hospitals are not permitted to comply according to CMS.
Payors requiring secondary evaluation and approval of individuals with EMCs by insurer/payor-designated personnel as a condition for inpatient admission or transfer, including designation of transfer destination. 42 CFR 489.24(a)(1) requires that the MSE be performed by individuals determined qualified by hospital bylaws and regulations. If physician specialists are required to complete the MSE or provide stabilizing treatment for an EMC, 42 CFR 489.20(r) requires hospitals to maintain a list of on-call physicians who are on the hospital’s medical staff or have privileges. If the hospital lacks the capability or capacity to stabilize an EMC, it must make an appropriate transfer in accordance with 42 CFR 489.24(e).
Anecdotally we have become aware of some third-party payors with policies or proposed policies that seem to assume, incorrectly, that any individual for whom a transfer is being planned has been “stabilized,” and thus is no longer protected under EMTALA. As indicated above, this is incorrect, and procedures for a third-party payor to intervene in the transfer decisions regarding an individual protected under EMTALA could, if adhered to by hospitals, place them at risk of violating EMTALA.
COMMENT:
Just because a plan or even V.A. tells you the patient is stable and must be transferred to their facility or a plan hospital, they are not the ones who will be held responsible if the patient does not meet EMTALA criteria for a necessary transfer. You and your hospital will be the ones cited, and “they told us to do it” will not get you any slack.