So what about folks with co-pays and large deductible policies? With insurance companies cancelling millions of policies and employers reducing coverage in many instances or cutting folks back to part-time to avoid Obamacare, many of your ED “insured” visits will be severely under-insured and might not even realize that they are going to have to meet all or most of the ED visit charges out of their own pocket.
CMS has a rather lengthy warning on this aspect under EMTALA:
CMS has learned of instances where hospitals request immediate payment, by cash, check, or credit card, from individuals who are in the ED. Payment demands have been made for the current emergency services being offered to the individual, even though their ED encounter is still in progress, as well as for past hospital services.
The EMTALA regulations at 42 CFR 489.24(a)(1) explicitly require a hospital to provide any individual who comes to the ED a medical screening examination and, if applicable, stabilizing treatment, regardless of the individual’s ability to pay. Further, 42 CFR 489.24(d)(4)(i) explicitly prohibits a hospital from delaying examination or treatment in order to inquire about an individual’s method of payment or insurance status. However, in the interest of allowing hospitals to continue to engage in reasonable administrative practices that support efficient operations without violating the spirit of EMTALA, the provisions at 42 CFR 489.24(d)(4)(ii) and (iv) also describe permitted exceptions to the general prohibition on inquiring about method of payment or insurance status.
A request to an individual to make immediate payment for services required under EMTALA while such required services are being provided does not fall under either of the permitted exceptions, since it is neither a request for insurer authorization of screening and stabilizing treatment that has already been initiated (42 CFR 489.24(d)(4)(ii)), nor is it a component of a reasonable patient registration practice (42 CFR 489.24(d)(4)(iv)).
• Generally, beyond furnishing an insurance card or other evidence of insurance, the individual is not involved in the processing of a request for insurance authorization, nor is the individual’s stabilizing treatment disrupted when the hospital makes such a request to the insurer. Further, a request for insurer authorization is not a demand for immediate payment by the insurer. Accordingly, the regulation at 42 CFR 489.24(d)(4)(ii) permits such requests for insurer authorization to be made, but only after stabilizing treatment has been initiated, in order to assure that the request does not delay the screening examination and diagnosis of the individual’s condition.
• Likewise, hospitals, in accordance with 42 CFR 489.24(d)(4)(iv), are permitted to employ reasonable registration practices that neither delay screening or treatment, nor unduly discourage individuals from remaining for further evaluation. Asking an individual for basic identifying information, emergency contact information, whether he or she is insured and if so by whom, are permitted practices, so long as there is no delay in screening or treatment.
• Under Section 1867(h) of the Act and the regulation at 42 CFR 489.24(d)(4), a hospital is prohibited from delaying appropriate screening or stabilizing treatment to inquire about an individual’s method of payment. A request by the hospital for immediate payment by an individual who is protected under EMTALA goes well beyond a mere inquiry about payment method. Furthermore, a request for immediate payment risks creating the appearance that the hospital is linking provision of services required under EMTALA to the individual’s ability to pay, contrary to the requirement at 42 CFR 489.24(a)(1).
o The issue has been raised whether a request for the individual to make a payment is equivalent to a request for insurance authorization, making it therefore permissible under the regulation for a hospital to request payment, so long as the request is timed to occur after stabilizing treatment has been initiated. We see no basis for assuming these requests are equivalent, and thus a hospital’s request to an individual for payment is not covered by the regulation governing insurance authorization requests. Moreover, a request for payment could readily be interpreted by an individual protected under EMTALA as conditioning provision of care, or linking the extent of care offered, upon ability to pay, contrary to the requirement at 42 CFR 489.24(a)(1), regardless of the manner in which such request is made and regardless of whether the request is made after stabilizing treatment has been initiated.
o A request for payment carries a very high risk of unduly discouraging individuals, particularly those who lack the ability to pay, from remaining for further evaluation, and thus does not satisfy the reasonable registration process requirements of 42 CFR 489.24(d)(4)(iv).
Once a hospital’s EMTALA obligations to an individual have ended, i.e., the individual has been screened and determined not to have an EMC, or the individual’s EMC has been stabilized, or the individual with an unstabilized EMC has been admitted in good faith as an inpatient for stabilizing treatment, hospitals may make payment requests. In the case of a hospital (but not a CAH), the manner of the payment request must be consistent with the patient’s right under the hospital Conditions of Participation at42 CFR§482.13(c)(3) to be free from all forms of abuse or harassment.
COMMENT:
The OIG best practices rules are still in effect and severely restrict inquiries about insurance or payment until the MSE has been completed and necessary stabilizing care has been initiated. CMS has repeatedly found that any financial information prior to triage is a violation and that the family cannot be approached for registration information and financial information prior to the MSE and stabilizing care either.