CMS citations are allegations and should not be considered as conclusive on the facts. Submission of a plan of correction is not an admission of wrong-doing.
CMS cited a GA hospital for four separate EMTALA incidents where the allegations were:
Based on interviewing and record review the hospital failed to ensure that the the on-call specialist responded to emergency medical conditions regardless of pay source for four of 17 patients reviewed which resulted in these patients’ transfers to other hospitals for medical consultations, evaluations, and treatment.
Summary of Findings:
Number one is a three-year-old child complained of left knee pain. Emergency physicians notes indicated diagnosis of acute) a role fractured left femur. Patient was in pain and needed to have surgery to repair the fracture. The record indicates: “I spoke with the on-call orthopedic surgeon who request transfer as he does not accept the patient’s insurance.”
Patient 2’s insurance was in Medicaid managed care organization. Physician notes indicated diagnosis noted as acute appendicitis. The ED physician’s notes read “because of insurance reasons hospital 2 was called. Patient was transferred to hospital 2.” The transfer form lists the reason for transfer as “insurance”.
Patient 3 was diagnosed with acute appendicitis. The patient was insured through a Medicaid HMO and was a minor. The medical record indicates that the ED physician contacted the on-call surgeon and the patient was then transferred to hospital 2. The reason for transfer was listed as “funding/insurance”.
Patient 11 was insured by a Medicaid HMO. Patient’s diagnosis was chest pain, unstable angina. The patient was transferred to hospital two. There is no indication the on-call physician was called. The reason for transfer is listed as “insurance.”
The hospital policy for on-call physicians states “An on-call physician may not refuse a request from the dedicated emergency department physician to examine, treat, or accept the transfer of a patient on the basis of: the patient’s health plan membership, insurance status economic status or ability to pay.”
COMMENTS: Any inference of financial discrimination or even the potential for financial discrimination is a surefire grounds for a citation, so it is not surprising this hospital was cited, even though it had a policy in place against these types of financially-based incidents. The ground for citing the hospital is the basic failure to assure that these policies were being followed.
Hospitals are well-advised to have 100% quality review on all transfers as one of the necessary quality standards for EMTALA.
The hospital was fortunate, however, in that most regions would have also cited the failure of the on-call physicians to respond in several of these incidents as one violation in each case and the financial motivation as a separate violation in each case. The OIG may still consider the whole record and EMTALA regulations in deciding on the size of any hospital or physician fines.
A2404-11-5-25-CA