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Report No. 201

EMTALA (USA): (Anti-dumping law): Duties of hospitals:

The Emergency Medical Treatment and Labor Act, 1986 (EMTALA) is a federal law enacted by Congress as part of the Consolidated Omnibus Budget Reconciliation Act, 1985 (COBRA) (42 USC section 1395 dd), referred to by the Supreme Court in Paschim Banga Khet Mazdoor Samiti case 1996 (4) SCC 37.

The above Act is also known as the "anti-dumping" law, as it was designed to prevent hospitals from refusing to treat patients or transferring them to charity or public hospitals because the victims are unable to pay or had Medic-aid coverage. EMTALA requires hospitals with emergency departments to provide emergency medical care to everyone who needs it, regardless of ability to pay or insurance status. Under the law, the patients with similar medical conditions must be treated consistently. The law applies to hospitals that accept Medicare reimbursement and to all their patients, not just those covered by Medicare.

The Guide for Interfacility Patient Transfer published by the National Highway Traffic Safety Authority, USA (April, 2006) (NHSTA) gives a lot of details about the Act and various other particulars.

Under EMTALA (extracted in this chapter), the hospitals have these basic obligations:-

(1) The hospitals must provide all patients with a medical screening examination to determine whether an emergency medical condition exists without regard for ability to pay for services.

(2) Where an emergency medical condition exists, they must either provide treatment until the patient is stabilized, or if they do not have the capabilities, transfer the patient to another hospital.

(3) Hospitals with specialized capabilities are obliged to accept transfers if they have the capabilities to treat them. Medical care cannot be delayed by questions about methods of payment or insurance coverage.

Of course, under (1) if an appropriate medical screening examination identifies that no emergency medical condition exists, the EMTALA obligation ceases to exist. Under (2), no EMTALA obligation exists if an identified medical condition is stabilized. Additionally, latest regulations now recognize that a patient with an emergency medical condition may be discharged with a plan to have subsequent treatment provided as an outpatient if such a plan is consistent with medical routine and does not jeopardize the patient's health.

The NHTSA Guide further states that EMTALA governs how patients may be transferred from one hospital to another. Under the law, a patient is considered stable for transfer if the treating physician determines that no material deterioration will occur during the movement between facilities and that the receiving facility has the capability to manage the patients' medical condition. EMTALA does not control the transfer of a stable patient; however, patients with incompletely stabilized emergency medical condition may still be transferred under EMTALA if one of the two following conditions exists:

(a) the patient (or someone acting on the patients' behalf) provides a written request for transfer despite being informed of the hospitals' EMTALA obligations to provide treatment; or

(b) a physician certifies that medical benefits reasonably expected from transfer outweigh the risk to the individual.

Once a doctor has decided to transfer the individual, (points out the Guide), the following steps must be taken:

(i) the transferring hospital must provide all medical treatment within its capacity, which minimizes the risk to the individual's health.

(ii) the receiving facility must accept the transfer and must have space available and qualified personnel to treat the individual.

(iii) the transferring hospital must send copies of all medical records related to the emergency medical condition. If the physician on call refuses or fails to assist in the patient's case, the physician's name and address must be documented on the medical records provided to the receiving facility.

(iv) Qualified personnel, with the appropriate medical equipment, must accompany the patient during transfer. The transferring physician, by law, has the responsibility of selecting the most appropriate means of transport to include qualified personnel and transport equipment.

Under EMTALA, the patient care during transport is the responsibility of the transferring physician/hospital until the patient arrives at the receiving facility. The transferring physician is also responsible for the orders as to transfer and for the treatment orders to be followed during the transport. This may conflict with (US) State statutes, which in some instances, allow only authorized medical physicians to give orders to EMS personnel. EMTALA does not refer to the transport service and its medical directive, leaving ultimate medical responsibility and its transition during transport open for interpretation.

Certificate of necessity for transfer is a requirement for reimbursement by the Centres for Medicare and Medic-aid Services (CMS). The CMS definition of 'medical necessity' is as follows:

'Medical necessity is established when the patient's condition is such that use of any other method of transportation is contra-indicated. In any case, in which some means of transportation other than an ambulance could be utilized without endangering the individual's health, whether or not such other transportation is actually available, no payment may be made for ambulance service.'


The Centres for Medicare and Medic-aid Services has issued Regulations pertaining to the enforcement of this law. Regulations go into much greater details than the statute. Proposed rules published in 1988 can be found in the federal Register (June 16, 1988) (53 FR 22513). In the EMTALA, obligations are tied to hospitals' participation in Medicare. In fact, a hospital could relieve itself of EMTALA obligations by dropping out of the Medicare program; although this certainly would not be financially beneficial to the hospital (Guide for inter-facility patient transfer, April 2006, NHTSA, Appendix D, E).

Emtala Statute: (Emergency Medical Treatment and Labor Act)

Examination and Treatment For Emergency Medical Conditions and Women In Labor (42 U.S.C. ยง 1395dd)

"section 1867.

Emergency Medical Care to Victims of Accidents and during Emergency Medical Condition and Women under Labour Back

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