EMTALA

The Emergency Medical Treatment and Women in Labor Act (EMTALA) was developed by Congress to prevent hospitals from refusing to treat individuals requiring “emergency” care or inappropriately transferring or discharging individuals with unstable medical conditions. Reviews for EMTALA cases are conducted at the request of the CMS regional office by CCME Physician Consultants. The QIO (CCME) does not make determinations whether EMTALA was or was not violated; we do, however, identify the provision of medical screening examinations, stabilization of the patient. and comment on any identified quality of care issues.

When Medicare refers a case to CCME, there are two mandatory reviews that are performed for EMTALA cases:

• The 5-day review provides QIO medical expertise on whether the individual was adequately screened, examined, and treated. 

• The 60-day medical review is performed prior to the Office of Inspector General deciding on an imposition of civil monetary penalties or physician and/or hospital exclusion from the Medicare program. The hospital/physician is provided an opportunity to discuss the case(s) and to submit additional information.

Our physician reviewers address specific questions using his or her medical judgment pertinent to an alleged dumping case. The review will address whether: 

• The individual had an emergency medical condition.
• The individual's emergency medical condition was stabilized.
• The individual was transferred appropriately.
• The certification that the benefits of transfer outweighed the risks was correct.
• There was any medical utilization or quality of care issues involved in the case.

Results of the review by CCME are reported to the CMS regional office. We do not state an opinion regarding whether an EMTALA violation has occurred. The CMS regional office can report the findings to the hospital or physician consistent with confidentiality requirements.

For details about the EMTALA regulation, please visit the Medicare website at www.cms.gov/emtala. If you have questions about EMTALA, contact Linda Moore, RN, at lmoore@scqio.sdps.org.

Reporting a Potential EMTALA Violation
If you believe a potential EMTALA violation has occurred, please contact
1-800-MEDICARE.