JOHN SHUFELDT, MD, JD, MBA, FACEP
I was an emergency medicine resident on the south side of Chicago in the mid-1980s and, truth be known, I sometimes played inappropriate practical jokes on residents at other area trauma centers. One of my favorites was calling over the “patch phone” with a report that a patient whose penis was “Lorena Bobbitted” by a pit bull was en route; the paramedics were bringing in both the patient and the dog so that a “reimplantation” could be attempted post vivisection of the dog.
My other favorite was the one where multiple severely handicapped children were coming in post minor bus accident for evaluation, with their parents not readily available. Anyway, usually the calls concluded with the recipient resident saying things like, “Oh yeah, why don’t you bite me?” Calling emergency departments from an urgent care is sometimes a traumatic experience made worse by some ED physician giving you the third degree about “what you are dumping on us?” and muttering something about EMTALA (the Emergency Medical Treatment and Active Labor Act) and hanging up phone while swaying “bite me!”
Urgent Care Obligations
Do urgent care centers have any obligation under EMTALA? The answer is: it depends.
If the urgent care center is owned and operated by the hospital and is under the same Medicare provider number and meets the Centers for Medicare & Medicaid Services’ definition of a “dedicated emergency department” by meeting one of the following criteria: 1) is licensed by the state as an emergency department; 2) holds itself out to the public as providing emergency care; or 3) during the preceding calendar year, provided at least one-third of its visits for the treatment of emergency conditions, then the answer is yes.
However, does EMTALA apply if the urgent care center operates independently from the hospital (different provider number) and sees less than 33% walk-in patients with emergency conditions? Or, what if an urgent care advertises that it only treats urgent conditions and nor emergent conditions; is that center exempt from EMTALA? The answer to both those scenarios is (I hate to answer like a lawyer) more likely than not, EMTALA does not apply. CMS does retain the right to review claims on a case-by-case basis. In other words, they can use the dreaded “retrospectoscope” to evaluate the relationship and then pass judgment.
The take-home point is this: If you are working at a hospital-owned urgent care center which makes no distinction on the types of patients treated and sees patients who may qualify as an “emergency,” you have some EMTALA exposure. Therefore, the same EMTALA policies used in the emergency department should be in place at the hospital urgent care center. For example, not taking insurance information until an appropriate screening exam is completed, stabilizing prior to appropriate transfers, and providing an appropriate screening exam for all corners.
Occasionally, urgent care physicians tell me that when they do call to alert an emergency physician, they are given the third degree by the recipient and are often told that the ED won’t accept the patient. Do you need to call an emergency department from a physician-owned urgent care prior to transfer? Absolutely not! In a perfect world, communicating with a receiving provider should be commonplace; this direct communication facilities the continuum of care and allows the sending provider to alert the receiving provider about what has already transpired and what the concerns or issues are regarding the patient.
What should not occur, however, is the sending provider receiving the third degree by some overworked, burned out EM physician. At the end of the day, the emergency department cannot refuse the patient no matter how inappropriate they believe the transfer, unless the ED is closed to ambulance traffic. And even if they are closed to ambulance transfers, they cannot refuse a patient who is being transferred by private vehicle.
Effective Provider-to-Provider Communication
There are other ways to communicate important facts germane to the patient who is changing venues to the emergency department. When I work in the ED, I don’t necessarily want to hear from an urgent care provider who is transferring a patient to my care. I simply don’t want to be biased by their concerns.
What I do expect, however, is a written record of the history, exam, radiographs, and lab results, as well as a written statement identifying the UC provider’s concern. “This 67-year-old diabetic patient presents with abdominal pain out of proportion to exam findings and I am concerned about the possibility of ischemic bowel.”
If you feel more comfortable communicating directly with the receiving physician, more power to you, although don’t let yourself be the recipient of any abuse.
When I transfer a patient, I call after the patient has already left the urgent care and I keep my communication fact-based: “I just sent you a 48-year-old man with a good story for acute coronary syndrome. His EKG, CXR and troponin are normal, as well as his d-dimer. He has hypertension and a family history of coronary artery disease and should be there in about 10 minutes.”
This leaves the emergency physician no out; the patient is on his way. Compare this method with “I’m thinking about sending a patient who may have angina. Everything else is normal but I’m not sure what else to do. Would you mind if I sent him your way?”
You get the picture. If you are constantly getting pushback from the ED, choose another receiving hospital or, if you have to use the particular ED, quit calling. After all, you are sending them a patient who will augment their income; why should you be abused?