CMS Memo Regarding EMTALA On-Call Requirements & Remote Consultation

[CAL/AAEM News Service]

CMS Memo Regarding EMTALA On-Call Requirements & Remote Consultation

Source: AAEM (http://www.aaem.org)
Date: July 13, 2007


The Centers for Medicare & Medicaid Services (CMS) recently sent out a memo
regarding EMTALA On-Call Requirements and Remote Consultation Utilizing
Telecommunications Media.

Memorandum Summary
*The treating physician in a hospital’s or critical access hospital’s (CAH)
dedicated emergency department (DED) who is conducting the medical screening
examination and/or providing stabilizing treatment of an individual required
by the EMTALA regulations at 42 CFR 489.24 may, without violating EMTALA,
consult on the individual’s case with a physician who is not present in the
DED by means of any telecommunications medium that the physicians choose to
use.
*This does not change the obligation under EMTALA of a physician who is
on-call to make an in-person appearance in the DED when requested to do so
by the treating physician.
*This guidance does not affect policy by any health care third party payer,
including Medicare, governing the circumstances under which it will or will
not pay for remote consultation services.
*The portions of the interpretative guidelines for 42 CFR 489.20(r) and
§489.24(j) that discuss telemedicine or telehealth are superceded by this
guidance.

It has been brought to the attention of the Centers for Medicare & Medicaid
Services (CMS) that the interpretative guidelines for 42 CFR 489.20(r) and
§489.24(j), concerning hospital/CAH on-call physician requirements under
EMTALA, are being interpreted by some parties as prohibiting emergency
department physicians from utilizing modern telecommunications to facilitate
consultation with specialists who are not present in the hospital/CAH. There
is no such prohibition under EMTALA. It is necessary to distinguish among:

*a hospital’s/CAH’s obligation under EMTALA to maintain an on-call list of
physicians on its medical staff in a manner that best meets the needs of its
patients;
*the obligation of an on-call physician to make an in-person appearance when
requested to do so by the physician who is treating an individual who has
come to the emergency department of the hospital/CAH; and
*remote consultation on the individual’s case by the treating physician with
another physician, who may or may not be on the hospital’s/CAH’s on-call
list.

The EMTALA statute at Sections 1866 and 1867 of the Social Security Act and
EMTALA regulations at 42 CFR 489.20(r) and §489.24(j) establish requirements
regarding hospital/CAH on-call lists and the obligations of on-call
physicians to make in-person appearances. These provisions apply to
hospitals/CAHs participating in Medicare. Section 1866(a)(1)(I)(iii) and 42
CFR section 489.20(r)(2) require hospitals/CAHs to “maintain a list of
physicians who are on call for duty after the initial examination to provide
treatment necessary to stabilize an individual with an emergency medical
condition.” Each hospital/CAH must maintain its on-call list in a manner
that best meets the needs of the hospital’s patients who receive services
required under EMTALA. The resources available to a hospital/CAH, including
the availability of on-call physicians, are taken into account when
assessing the adequacy of its on-call list.

There is no EMTALA prohibition against the treating physician consulting on
a case with another physician, who may or may not be on the hospital’s or
CAH’s on-call list, by telephone, video conferencing, transmission of test
results, or any other means of communication. CMS is aware that it is
increasingly common for hospitals/CAHs to use telecommunications to exchange
imaging studies, laboratory results, EKG’s, real-time audio and video images
of patients, and/or other clinical information with a consulting physician
not on the hospital/CAH premises. Such practices may contribute to improved
patient safety and efficiency of care. In some cases it may be understood by
the hospitals/CAHs and physicians who establish such remote consulting
arrangements that the physician consultant is not available for an in-person
assessment of the individual at the treating physician’s hospital/CAH.

However, if a physician:
*is on a hospital’s or CAH’s on-call list; and
*has been requested by the treating physician to appear at the hospital; and
*fails or refuses to appear within a reasonable period of time,
then the on-call physician may be subject to sanctions for violation of the
EMTALA statutory requirements.

It is only when the treating physician requests an in-person appearance by
the on-call physician that a failure by the latter to appear in person may
constitute an EMTALA violation.

It is an entirely separate issue, outside the scope of EMTALA enforcement,
whether or not insurers or other third party payers, including Medicare,
will provide reimbursement to physicians who provide remote consultation
services.

This clarification of existing policy will be incorporated into the SOM,
Appendix V the next time it is revised.

For questions on this memo, please contact Donna Smith at (410) 786-3255 or
by e-mail at Donna.Smith at cms.hhs.gov.




Cyrus Shahpar & Brian Potts 
Managing Editors, CAL/AAEM News Service
University of California, Irvine

The CAL/AAEM Archives are available at: http://maillists.uci.edu/mailman/public/calaaem/



       
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