On June 23, 2017, a South Carolina-based hospital system, AnMed Health, agreed to pay $1,295,000 to settle allegations that it violated the Emergency Medical Treatment and Labor Act (EMTALA). The HHS OIG alleged AnMed held individuals with unstable psychiatric conditions in its emergency department (ED) rather than admitting them as inpatients. This is the largest settlement ever under EMTALA, and suggests OIG may take similar enforcement actions in the future. The settlement raises questions that OIG’s interpretation of EMTALA may impose broader obligations than some hospitals have traditionally understood their obligations to be under the law.

According to the settlement agreement, available here, individuals allegedly presented at AnMed’s ED with psychiatric emergency medical conditions, and AnMed did not provide psychiatric examination and treatment by an on-call psychiatrist. Instead, ED physicians performed evaluations and treatment, and boarded the individuals in the ED between 6 and 38 days. During this time, AnMed allegedly had available inpatient beds in its psychiatric unit and available on-call psychiatrists. OIG asserted these actions violated EMTALA.

EMTALA Requirements

Under EMTALA, a hospital must provide an appropriate Medical Screening Exam (MSE) to all individuals to come to the hospital to determine whether an Emergency Medical Condition (EMC) exists. An MSE must be performed by a qualified medical personnel in a non-discriminatory manner, and must be sufficient to allow the qualified medical personnel to determine whether an EMC exists. If an EMC exists, or if it is unable to be determined, the hospital must provide stabilizing treatment or an appropriate transfer. See 42 C.F.R. § 489.24(a)(1).

AnMed’s Alleged Violations

Utilization of On-Call Specialists

The settlement suggests that OIG expects hospitals with psychiatric capabilities to require on-call psychiatrists to perform MSEs on all patients who present with psychiatric symptoms. In the settlement agreement, OIG repeatedly cites incidents where AnMed “appeared to have violated [EMTALA]” when individuals “did not receive psychiatric examination or treatment by available AnMed psychiatrists.”

However, EMTALA only requires that an appropriate MSE is performed by qualified medical personnel to determine whether an EMC exists. If the qualified medical personnel cannot determine whether an EMC exist, only then would an on-call specialist, like a psychiatrist, be required. Under the current law, if the qualified medical personnel can determine that an EMC exists, the hospital does not have a duty to consult with an on-call specialist.

Based on OIG’s allegations in the AnMed settlement, it appears that OIG either does not believe a qualified medical personnel has the ability to determine whether an individual is presenting with a psychiatric emergency, or OIG believes hospitals have broader EMTALA obligations for individuals with psychiatric mental issues than it does for individuals with physical health issues.

Definition of “Stabilization” for Psychiatric Emergency Conditions

Under EMTALA, hospitals are required to provide stabilizing treatment to individuals who present with an EMC. Stabilizing treatment requires “such care necessary to assure, within reasonable medical probability, that no material deterioration of condition is likely to result from or occur during transfer from facility.” 42 C.F.R. § 489.24(d). Additionally, it has traditionally been understood that EMTALA does not require treatment of the underlying issue.

Whether an individual with a psychiatric EMC is stable may be a difficult determination. CMS has defined stability for psychiatric individuals when they are protected and prevented from injuring or harming themselves or others. See CMS Interpretive Guidelines on EMTALA, Tag A-2407/C-2407. The use of chemical or physical restraints may stabilize the symptoms and remove the immediate danger, but the underlying psychiatric EMC may persist and not actually be stabilized. Once the individual is stable, the hospital’s EMTALA obligations ends. Under EMTALA, a hospital is not obligated to admit the individual as an inpatient. There may be standard of care issues or state law requirements that could be implicated by not admitting the individual, but there is not a duty under EMTALA to do so.

OIG’s settlement suggests that the agency defines stabilization more broadly, and may expect hospitals to resolve the underlying EMC within its capabilities. Further, OIG appears to expect hospitals with available inpatient psychiatric beds to admit individuals presenting with psychiatric EMCs.

Hospitals with inpatient psychiatric units may wish to review its EMTALA procedures and CMS guidance to assess its EMTALA risk and should be prepared for increased OIG scrutiny.