Hospital and Physician Requirements under EMTALA

Published on: January 27, 2025

The Emergency Medical Treatment and Labor Act (EMTALA) of 1986 is a federal law aimed at ensuring public access to emergency medical services regardless of a patient’s ability to pay for those services.  The primary intent of EMTALA is to prevent instances of “patient dumping,” in which hospitals refuse to treat uninsured patients or transfer them to other facilities without providing adequate medical evaluation and care.

EMTALA imposes several requirements on Medicare-participating hospitals that offer emergency services, and physicians with staff privileges at those hospitals may also have individual obligations under EMTALA.

Hospital Requirements

When a patient arrives at a hospital emergency department (ED) and requests examination or treatment for an emergency medical condition, including active labor, the hospital is required to provide the following:

Medical Screening Examination
An appropriate Medical Screening Examination (MSE) must be conducted by qualified medical personnel, which often includes a physician, to determine if an emergency medical condition (EMC) exists.

Stabilizing Treatment
If an EMC is identified during the MSE, the hospital must provide treatment to stabilize the condition.  Stabilization involves providing necessary medical treatment to ensure that no material deterioration of the patient’s condition is likely to result from transfer or discharge from the hospital.  Physicians play a crucial role in diagnosing, treating, and making decisions regarding the stabilization of patients under EMTALA.

Appropriate Transfer
In cases where a hospital does not have the capability or capacity to stabilize a patient with an EMC, the patient can be transferred to another facility.  However, this transfer must meet specific EMTALA requirements:

• The transferring hospital must provide medical treatment within its capacity to minimize the risks to the patient’s health.
• The receiving facility must have available space and qualified personnel to treat the patient and must agree to accept the transfer.
• All relevant medical records, including the MSE and treatment provided, must accompany the patient.
• The transfer must be carried out through qualified personnel and transportation equipment, including life support measures if necessary.

Hospitals with specialized capabilities or facilities, such as burn units or neonatal intensive care units, are obligated to accept transfers of patients requiring such specialized care, provided they have the capacity to treat the patients.

Physician Requirements

EMTALA requires hospitals to maintain a list of on-call physicians who are available to provide further evaluation and treatment necessary to stabilize patients with EMCs.  Hospitals are not required to have 24-hour specialty services available; it is up to their discretion to determine what specialty services should be available on-call to meet their EMTALA obligation.

EMTALA does not independently require physicians to take call.  However, on-call requirements for staff physicians are often written into medical staff bylaws and/or contracts, meaning that physicians who serve on a hospital medical staff may be required to take call as a condition of maintaining treatment privileges.

Physicians who have a responsibility to be on call must respond promptly to calls from the ED to provide necessary screening examinations or care, during the times that they are actively on call, unless circumstances beyond their control prevent them from responding.  Failure of on-call physicians to fulfill their duties can result in EMTALA violations, as discussed below.

Of note, in the event of a disagreement between providers, it is up to the judgment of the requesting ED physician as to whether an EMC is present, and whether the on-call physician responds within a “reasonable period of time.”  Physicians who are involved in EMTALA care must participate in any evaluation to determine the existence of an EMC, provide stabilizing care, and/or participate in the transfer of the patient to another facility.

Importantly, physicians are not obligated to provide follow-up care for patients who are evaluated and/or treated under EMTALA.  However, it is recommended that physicians attempt to coordinate or facilitate follow-up care as appropriate, given the nature of the EMC and the treatment provided.  Also, hospitals may have independent requirements for staff physicians in terms of follow-up of emergency care.

When EMTALA Does and Does Not Apply

EMTALA applies when a patient is brought to the hospital via Emergency Medical Services; when a patient presents to the hospital or is on the hospital property and within 250 yards of the hospital; or when a hospital receives a transfer request from another hospital’s emergency department.  EMTALA does not apply to outpatient physician offices or clinics, direct physician admission to an inpatient unit, telephone calls, or any non-hospital healthcare entity such as surgical centers or skilled nursing facilities.

EMTALA obligations end once a patient has been (any one of these may apply):

• screened by a qualified medical practitioner and determined not to have an emergency medical condition
• provided with care to stabilize the emergency medical condition, even if ongoing care is needed
• admitted to the hospital as an inpatient in good faith (not in observation status)
• transferred safely to another hospital that assumes EMTALA obligation
• confirmed to refuse further care

Violations and Consequences under EMTALA

Several types of violations can occur under EMTALA, including but not limited to:

• Failure to conduct an appropriate Medical Screening Examination (MSE)
• Refusal to treat a patient with an emergency medical condition
• Improper transfer of a patient to another facility
• Failure to stabilize a patient before discharge or transfer
• Inadequate on-call coverage or failure of on-call physicians to respond
• Failure to accept appropriate patient transfers when specialized capabilities are available

While CMS can only terminate Medicare participation for hospitals that violate EMTALA, the HHS Office of the Inspector General (OIG) has legal authority to impose civil monetary penalties against hospitals and/or physicians for EMTALA violations.  The penalties for EMTALA violations can be severe and include:

• Monetary fines of up to $104,826 per violation for hospitals with 100 or more beds, and up to $52,414 per violation for hospitals with fewer than 100 beds
• Monetary fines of up to $50,000 per violation for physicians who fail to respond to calls within a reasonable timeframe
• Medicare program exclusion for hospitals or physicians found to be in violation
• Private legal action by the patient or another medical facility for damages

MIEC recommends the following:

1. Review hospital by-laws, policies and procedures, and/or contracts to verify your on-call requirements and develop an on-call schedule that meets those requirements.
2. When you are actively on call, ensure that the ED knows how to reach you and respond as soon as possible when contacted as the on call physician.
3. Work with the hospital to develop a backup plan in the event that the on-call physician cannot respond due to circumstances beyond their control.
4. When contacted by the ED and determining whether a patient requires consultation or care for an emergency condition, you should defer to the clinical judgment of the requesting ED physician.
5. Document all discussions with the Emergency Department, including telephone consultations that do not involve direct examination or treatment of a patient.
6. When involved in providing care under EMTALA, communicate clearly with patients regarding your availability to provide follow-up care; when possible, offer to provide or coordinate follow-up care to avoid gaps in the continuity of care.