Since its inception, there has been considerable discussion and disagreement as to whether EMTALA applies to inpatients. This ambiguity is easy to understand upon a cursory examination of the operative provisions of the statute (detailed in other sections on EMTALA-INFO.com):
- The “screening” subsection of the statute, subsection (a), is applicable to “any individual” who “comes to the emergency department” of an eligible hospital seeking treatment of a medical condition;
- The “stabilization” subsection, subsection (b), is applicable to “any individual” who “comes to a hospital and the hospital determines that the individual has an emergency medical condition”;
- Finally, the “restriction on transfers” provision, subsection (c), is applicable to “any individual at a hospital” and who has an emergency medical condition that has not been stabilized.
As can quickly be seen, Congress did not use consistent language to define the classes of individuals for whose protection EMTALA applies. Furthermore, none of these key terms are defined by the statute.
In 2003, Centers for Medicare and Medicaid Services (CMS), of the Department of Health and Human Services (DHHS), the administrative agency charged with interpreting and implementing EMTALA, issued its final rules clarifying hospital responsibilities under the Act. CMS expressly endorsed the approach of several courts and directed that a hospital’s obligation to stabilize a patient under EMTALA ends upon inpatient admission to the hospital. See, 42 C.F.R. § 489.24(a)(1)(ii) and (d)(2). There is an exception to the general rule where the hospital admits the patient as a subterfuge for avoiding liability under EMTALA, requiring the admission to be in “good faith in order to stabilize the emergency medical condition.” See, 42 CFR § 489.24 (d)(2)(i). The preamble stresses this exception, stating that a hospital may still be liable if it does “not admit an individual in good faith with the intention of providing treatment (that is, the hospital [uses] the inpatient admission as a means to avoid EMTALA requirements).” What this interpretation also means is that a hospital with specialized capabilities has no obligation to accept a transfer of an inpatient, given that these patients do not fall under the sway of EMTALA, as opposed to the obligation to accept the transfer of an individual who was treated only in the emergency room of the first hospital. Several courts, both prior to and following these regulations, have adhered to CMS’s interpretation of the statute. See, e.g., Bryant v. Adventist Health Sys., 289 F.3d 1162 (9th Cir. 2002); Bryan v. Rectors and Visitors of the Univ. of Virginia, 95 F.3d 349 (4th Cir. 1996). There were, however, other Circuits that disagreed with this interpretation, citing the different language used by Congress in the three subsections, as detailed above. See Lopez-Soto v. Hawayek, 175 F.3d 170 (1st Cir. 1999); Lima Rivera v. UHS of Puerto Rico, 476 F. Supp. 2d 92 (2007).
The most important case on this issue came in 2009, when the Sixth Circuit issued its opinion in Moses v. Providence Hospital and Med. Ctr., 561 F.3d 573 (6th Cir. 2009). In that case, the court rejected CMS’s interpretive regulations on this issue, finding them to be an impermissible agency construction that was contrary to the plain text of the statute pursuant to the standards in Chevon, U.S.A. v. Natural Res. Def. Council, Inc., 467 U.S. 837 (1984). The Moses court was persuaded by the different language used by Congress in the above-noted subsections and by the definition of the term stabilized as meaning “no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during” the patient’s release from the hospital. Id. at 582. The court ultimately concluded that EMTALA required “more than the admission and further testing of a patient; it requires that actual care, or treatment, be provided as well.” Id.
A certiorari petition to the Supreme Court was filed in the Moses case, but the Supreme Court declined to hear the case. However, this activity and the decision in Moses prompted CMS to reconsider its prior regulations in 2010 and sought additional commentary from the medical community of the application of EMTALA to individuals who have been admitted to inpatient care for further treatment. In 2012, after comment, CMS specifically declined to reconsider its prior stance.
At this point, there remains a minor split of authority amongst the Circuits as detailed above regarding the interpretation of EMTALA and its application to inpatients. This has implications for both the initial hospital that receives a patient in the emergency room, as well as any other prospective hospital that would receive a patient transfer, given that they are not required to accept a transfer of an inpatient under EMTALA. Hospitals should know that the law is unsettled here. If the hospital is not located in a circuit that has either accepted CMS’s interpretation or ruled consistent with but prior to issuance of the regulations (the 4th and 9th), or rejected the interpretation (the 6th), it is difficult to predict how a Circuit Court would rule on this issue, and the Supreme Court does not appear inclined to address this issue.
Furthermore, with respect to the screening requirement, there is very little case law considering whether the screening requirement applies to an individual who presents to the emergency room and is admitted for inpatient care. Presumably, if the hospital admitted the patient to inpatient care, then there is a very strong argument that the purpose of the statute with respect to mandating appropriate screening has been satisfied. See Preston v. Meriter Hosp., Inc., 2008 WI App 25, P54 (Wis. Ct. App. 2008) (concluding that “that there is no principled basis upon which to distinguish between the screening requirement and the stabilization requirement in the context of a person’s status as an inpatient.”); Morgan v. North Mississippi Med. Ctr., Inc., 403 F. Supp. 2d 1115, 1127 (S.D. Ala. 2005) (“The Court’s research has disclosed no authorities, and plaintiff has cited none, in which EMTALA’s screening duty has been extended to an inpatient some eight days post-admission to the hospital.”) However, one could argue that if an inappropriate (i.e. non-uniform) screening is performed initially, this failure could lead to further complications even after the patient is admitted for inpatient service. This issue has yet to be fully developed, but be sure check back to EMTALA-INFO.com for more information if it becomes available.
Click here for relevant opinions on Inpatient Status.