CHAPTER VI: PROVIDER-BASED ENTITIES
OBJECTIVES
BACKGROUND
DEFINITIONS
Campus
Main Provider
Department of a Provider
Provider-Based Entity
Remote Location of a Hospital
Provider-Based Status
Free-Standing Facility
REQUIREMENTS FOR PROVIDER-BASED ENTITY OR DEPARTMENT OF PROVIDER
Licensure
Ownership and Control
Administration and Supervision
Clinical Services
Financial Integration
Public Awareness
Location in Immediate Vicinity
ADDITIONAL PROVISIONS
Joint Ventures
Management Contracts
RESPONSIBILITY FOR OBTAINING PROVIDER-BASED DETERMINATIONS
OBLIGATIONS OF HOSPITAL OUTPATIENT DEPARTMENTS AND HOSPITAL-BASED ENTITIES
INAPPROPRIATE TREATMENT OF A FACILITY OR ORGANIZATION AS PROVIDER-BASED/MAIN PROVIDER PAYMENTS
Determination and Review
Good Faith Effort
INAPPROPRIATE BILLING
Notice to Provider
Adjustment of Payments
Review of Previous Payments
Determination Regarding Provider-Based Status
CONTINUATION OF PAYMENT
OTHER ISSUES
Correction of Errors
FQHC Facilities
Indian Health Services (IHS) and Tribal Facilities
PHYSICIAN SUPERVISION REQUIREMENTS
Therapeutic Services
Definition: Direct Physician Supervision
Application
Diagnostic Services
SPECIAL RESPONSIBILITIES OF MEDICARE HOSPITALS IN EMERGENCY CASES
Definition Change
Hospital Responsibilities
CHAPTER VI: PROVIDER-BASED ENTITIES
OBJECTIVES
The objective of this chapter is to provide participants with an understanding
of the Final Rule on provider-based status published in the April 7, 2000,
Federal Register. At the end of this session, participants obtain an understanding of:
- The general requirements for status as provider-based entity or department of a provider.
- Specific provisions relating to joint ventures and management contracts.
- Responsibilities of the provider for obtaining provider-based determinations.
- Provisions for recovery, as a result of inappropriate treatment of a facility or organization as provider-based.
- Obligations of hospital outpatient departments and hospital-based entities.
BACKGROUND
Medicare has defined various types of providers of services but has never defined
in Medicare law the term "provider-based." However, from the beginning
of the Medicare program, some providers have owned and operated other facilities,
such as SNFs or HHAs, that were administered financially and clinically by the
main provider. The subordinate facilities may have been located on the main
provider campus or may have been located away from the main provider.
In order to accommodate the financial integration of the two facilities without
creating an administrative burden, HCFA has permitted the subordinate facility
to be considered provider-based. The determination of provider-based status
allowed the main provider to achieve certain economies of scale. To the extent
that overhead costs of the main provider, such as administrative, general, housekeeping,
etc., were shared by the subsidiary facility, these costs were allowed to flow
to the subordinate facility through the cost allocation process in the cost
report. This was considered appropriate because these facilities were also operationally
integrated, and the provider-based facility was sharing the overhead costs and
revenue producing services controlled by the main provider.
Before implementation of the hospital inpatient PPS in 1983, there was little
incentive for providers to affiliate with one another merely to increase Medicare
revenues or to misrepresent themselves as being provider-based, because at that
time each provider was paid primarily on a retrospective, cost-based system.
At that time, it was in the best interest of both the Medicare program and the
providers to allow the subordinate facilities to claim provider-based status,
because the main providers achieved certain economies, primarily on overhead
costs, due to the low incremental nature of the additional costs incurred.
In the proposed rule, HCFA noted the increase of provider-based facilities
and the financial and organizational incentives for that increase since 1983.
A variety of factors such as the emergence of integrated delivery systems and
the pressure to enhance revenues have combined to create incentives for providers
to affiliate with one another and to acquire control of traditionally non-provider
treatment settings, such as physician offices.
<>HCFA noted in the proposed rule that it is essential to make decisions regarding
provider-based status appropriately, and that we have clear rules for identifying
provider-based entities.
One example given in the proposed rule is a beneficiary treated in a physician’s
office versus a hospital outpatient clinic. When the beneficiary is treated
in a physician’s office, the only payment made is Part B payment to the
physician for his or her professional services, under the physician fee schedule.
The single payment made under the physician fee schedule pays for the physician’s
work and includes a component for practice expense. The beneficiary’s coinsurance
is based on 20 percent of the physician fee schedule amount. If the same services
is furnished in a hospital outpatient clinic, Medicare
Part B payment for a facility fee is also made to the hospital, in addition
to the physician’s payment (with a reduced practice expense component)
and the beneficiary’s coinsurance is based on 20 percent of the hospital’s
charges.
The effective date of the "provider-based" regulations is six months
after the publication of the Final Rule, or 10/10/2000.
DEFINITIONS
The Final Rule provides definitions and general requirements for the determination
of provider-based status. In addition to provider-based status, the following
terms are also defined:
- Main provider
- Campus
- Department of a provider
- Provider-based entity
- Remote location of a hospital
- Free-standing facility
Campus
A campus means the physical area immediately adjacent to the provider’s
main buildings, other areas and structures that are not strictly contiguous
to the main buildings but are located within 250 yards of the main buildings.
A campus will also include any other areas determined on an individual case
basis, by the HCFA regional office, to be part of the provider’s campus.
Main Provider
A main provider means a provider that either creates, or acquires ownership
of, another entity to deliver additional health care services under its name,
ownership, and financial and administrative control.
Department of a Provider
A department of a provider means a facility or organization or a physician
office that is either created by, or acquired by, a main provider for the purpose
of furnishing health care services under the name, ownership, and financial
and administrative control of the main provider.
A department of a provider may not be licensed to provide health care services
in its own right, and Medicare conditions of participation do not apply to a
department as an independent entity.
The term department of a provider would not include an RHC or FQHC. HCFA has
determined that RHCs will be defined as "provider-based" entities.
In addition, HCFA has established special provisions for FQHCs that will be
addressed later in this chapter.
Provider-Based Entity
A provider-based entity is a provider of health care services, or an RHC that
is either created by, or acquired by, a main provider for the purpose of furnishing
health care services of a different type from those of the main provider. A
provider-based entity will operate under the name, ownership, and administrative
and financial control of the main provider.
Remote Location of a Hospital
The term "remote location of a provider" is used to describe a facility
or an organization that is either created by, or acquired by, a hospital that
is a main provider for the purpose of furnishing inpatient hospital services.
As with a "department of a hospital," a remote location of a hospital
operates under the name, ownership, and financial and administrative control
of the main provider.
A remote location of a hospital may not be licensed to provide inpatient hospital
services in its own right, and Medicare conditions of participation do not apply
to a department as an independent entity. The term "remote location of a hospital"
does not include a satellite facility.
Provider-Based Status
The term "provider-based status" will be used to describe the relationship
between a main provider and a provider-based entity or a department of a provider,
remote location of a hospital, or satellite facility that complies with the
Final Rule.
Free-Standing Facility
The term "free-standing facility" is used to describe an entity that
furnishes health care services to Medicare beneficiaries and that is not integrated
with any other entity as a main provider, a department of a provider, or a provider-based
entity.
REQUIREMENTS FOR PROVIDER-BASED ENTITY OR DEPARTMENT OF PROVIDER
HCFA has defined specific requirements for provider-based entities or departments
of providers. All the defined criteria must be met.
Licensure
The department of the provider, remote location of the hospital, or satellite
facility and the main provider are operated under the same license, except in
areas where the state requires a separate license or in states where state law
does not permit licensure under a single license.
If a state health facilities' cost review commission (or other agency that
has authority to regulate the rates charged by hospitals or other providers
in a state) finds that a particular facility or organization is not part of
a provider, HCFA will determine that the facility or organization does not have
provider-based status.
Ownership and Control
The facility or organization seeking provider-based status must be operated
under the ownership and control of the main provider. The following requirements
must be met:
- The business enterprise that constitutes the facility or organization must be 100 percent owned by the main provider.
- The main provider and the facility or organization seeking status as a department of the provider,
remote location or satellite facility must have the same governing body.
- The facility or organization must be operated under the same organizational
documents as the main provider.
- The main provider must have final responsibility for administrative decisions,
final approval for contracts with outside parties, final approval for personnel
actions, final responsibility for personnel policies (such as fringe benefits/code
of conduct), and final approval for medical staff appointments in the facility
or organization.
Administration and Supervision
The reporting relationship between the facility or organization seeking provider-based
status and the main provider must have the same frequency, intensity, and level
of accountability that exists in the relationship between the main provider
and one of its departments, as evidenced by compliance with all of the following requirements:
- The facility or organization is under the direct supervision of the main provider.
- The facility or organization is operated under the same monitoring and oversight
by the provider as any other department of the provider, and is operated just
as any other department of the provider with regard to supervision and accountability.
The facility or organization director or individual responsible for daily
operations at the entity must maintain a day-to-day reporting relationship
with a manager at the main provider, and be accountable to the governing body
of the main provider, in the same manner as any department head of the provider.
- The following administrative functions of the facility or organization are
integrated with those of the provider where the facility or organization is based:
- billing services
- records
- human resources
- payroll
- employee benefit package
- salary structure
- purchasing services
The same employees or group of employees must handle these administrative functions
for the facility or organization and the main provider. The administrative functions
for either the facility or organization and the entity can be contracted out
under the same contract agreement or handled under different contract agreements,
with the contract of the facility or organization being managed by the main
provider's billing department.
Clinical Services
The clinical services of the facility or organization seeking provider-based
status and the main provider are integrated as evidenced by the following:
- Professional staff of the facility or organization have clinical privileges
at the main provider.
- The main provider maintains the same monitoring and oversight of the facility
or organization as it does for any other department of the provider.
- The medical director of the facility or organization seeking provider-based
status maintains a (day-to-day) reporting relationship with the chief medical
officer or other similar official of the main provider, that has the same
frequency, intensity and level of accountability that exists in the relationship
between the medical director of a department of the main provider and the
chief medical director of a department of the main provider and the chief
medical officer or other similar officer of the main provider and is under
the same type of supervision and accountability as any other director, medical
or otherwise, of the main provider.
- Medical staff committees or other professional committees at the main provider
are responsible for medical activities in the facility or organization including
quality assurance, utilization review, and the coordination and integration
of services, to the extent practicable, between the facility or organization
seeking provider- based status and the main provider.
- Medical records for patients treated in the facility or organization are
integrated into a unified retrieval system (or cross reference) of the main
provider.
- Inpatient and outpatient services of the facility or organization and the
main provider are integrated, and patients treated at the facility or organization
who require further care have full access to all services of the main provider
and are referred where appropriate to the corresponding inpatient or outpatient
department or service of the main provider.
Financial Integration
The financial operations of the facility or organization must be fully integrated
within the financial system of the main provider, as evidenced by shared income
and expenses between the main provider and the facility or organization. The
costs of the facility or organization are reported in a cost center of the main
provider and the financial status of the facility or organization is incorporated
and readily identified in the main provider's trial balance.
Public Awareness
The facility or organization seeking status as a department of a provider,
remote location or satellite facility is held out to the public and other payers
as part of the main provider. When patients enter the provider- based facility
or organization, they are aware that they are entering the main provider and
are billed accordingly.
Location in Immediate Vicinity
The facility or organization and the main provider are located on the same
campus, except as noted below.
High Level Integration
The facility or organization demonstrates a high level of integration with
the main provider by showing that it meets all of the other provider-based criteria,
and demonstrates that it serves the same patient population as the main provider,
by submitting records showing that, during the 12-month period immediately preceding
the first day of the month in which the application for provider-based status
is filed with HCFA, and for each subsequent 12-month period:
- At least 75 percent of the patients served by the facility or organization
reside in the same zip code areas as at least 75 percent of the patients served
by the main provider;
- At least 75 percent of the patients served by the facility or organization
who required the type of care furnished by the main provider received that
care from that provider (for example, at least 75 percent of the patients
of an RHC seeking provider-based status received inpatient hospital services
from the hospital that is the main provider); or
- If the facility or organization is unable to meet the criteria because it
was not in operation during all of the 12-month period, the facility or organization
is located in a zip code area included among those that, during all of the
12-month period described in the previous sentence, accounted for at least
75 percent of the patients served by the main provider.
Same State or Adjacent States
A facility or organization is not considered to be in the "immediate vicinity"
of the main provider unless the facility or organization and the main provider
are located in the same state or in an adjacent State, if this is not inconsistent
with the law of either State and other criteria are met, including those related
to services to the same patient population.
Rural Health Clinic
A rural health clinic that is otherwise qualified as a provider-based entity
of a hospital that is located in a rural area and has fewer than 50 beds, is
not subject to the criterion on services to the same potential patient population
as the main provider. However, the clinic is subject to the rule on location
in the same state as the main provider or, or in an adjacent State, if this
is not inconsistent with the law of either State and other criteria are met.
ADDITIONAL PROVISIONS
Joint Ventures
A facility or organization cannot be considered provider-based if the entity
is owned by two or more providers engaged in a joint venture. For example, where
a hospital has jointly purchased or jointly created free-standing facilities
under joint venture arrangements, neither party to the joint venture arrangement
can claim the free-standing facility as a provider-based entity.
Management Contracts
Facilities and organizations operated under management contracts are considered
provider-based if all of the following criteria are met:
- The staff of the facility or organization are employed by the provider or
by another organization other than the management company, which also employs the
staff of the main provider.
- The administrative functions of the facility or organization are integrated
with those of the main provider.
- The main provider has significant (day-to-day) control over the operations of the facility or organization.
- The management contract is held by the main provider itself, not by a parent
organization that has control over both the main provider and the facility
or organization.
RESPONSIBILITY FOR OBTAINING PROVIDER-BASED DETERMINATIONS
The final regulations state that a facility or organization is not entitled
to be treated as provider- based simply because it or the main provider believe
it is provider-based. A main provider or a facility or organization must contact
HCFA and be determined by HCFA to be provider-based, before they bill for services
as if the facility or organization were provider-based, or before it includes
costs of those services on its cost report.
Furthermore, a facility that is not located on the campus of a hospital and
is used as a site of physician services of the kind ordinarily furnished in
physician offices will be presumed to be a free-standing facility, unless it
is determined by HCFA to have provider-based status.
A main provider that creates or acquires a facility or organization for which
it wishes to claim provider-based status, including any physician offices that
a hospital wishes to operate as a hospital outpatient department or clinic,
must report the acquisition to HCFA if:
- The facility or organization is located off the campus of the provider.
- The inclusion of the costs of the facility or organization in the provider’s
cost report would increase the total costs on the provider’s cost report by at least 5 percent.
The main provider must furnish all information needed for a determination as
to whether the facility or organization meets the requirements for provider-based
status.
A material change in the relationship between a main provider and any provider-based
facility or organizations must also be reported to HCFA. Material changes could
include change in ownership or entry into a new or different management contract that could affect the
provider-based status of the facility or organization.
OBLIGATIONS OF HOSPITAL OUTPATIENT DEPARTMENTS AND HOSPITAL-BASED ENTITIES
Hospital outpatient departments and hospital-based entities must meet the following requirements:
- Hospital outpatient departments located either on or off the main premises
of the hospital must comply with anti-dumping rules.
- Physician services furnished in hospital outpatient departments or hospital-based
entities (other than RHCs) must be billed with the correct site-of-service
indicator, so that applicable site-of-service reductions to physician and
practitioner payment amounts can be applied.
- Hospital outpatient departments must comply with all the terms of the hospital's provider agreement.
- Physicians who work in hospital outpatient departments or hospital-based
entities are obligated to comply with non-discrimination provisions.
- Hospital outpatient departments (other than RHCs) must hold themselves out
to other payers as outpatient departments of that hospital, and must treat
all patients, for billing purposes, as hospital outpatients. The department
must not treat some patients as hospital outpatients and others as physician office patients.
- Services for a patient admitted to the hospital as an inpatient after receiving
treatment in the hospital outpatient department or hospital-based entity,
are subject to the payment window provisions applicable to PPS hospitals and
to hospitals and units excluded from PPS.
- When a Medicare beneficiary is treated in a hospital outpatient department
or hospital-based entity (other than an RHC), the hospital has a duty to notify
the beneficiary, prior to the delivery of services, of the beneficiary's potential
financial liability (that is, a coinsurance liability for an outpatient visit
to the hospital as well as for the physician service).
- Hospital outpatient departments must meet applicable hospital health and
safety rules for Medicare-participating hospitals.
INAPPROPRIATE TREATMENT OF A FACILITY OR ORGANIZATION AS PROVIDER-BASED/MAIN PROVIDER PAYMENTS
Determination and Review
If HCFA learns of a provider treating a facility or organization as provider-based
without notification to obtain a determination of provider-based status, the
following actions will be taken:
- All payments to that provider for all cost reporting periods subject to re-opening will be reconsidered.
- HCFA will investigate and determine whether the requirements for provider-based status were met.
In cases where the facility or organization would not qualify for a provider-based
determination, HCFA will recover the difference between the amount of payments
that actually were made and the amount of payments that should have been made
in the absence of a determination of provider-based status. Recovery will not
be made for any period prior to the effective date of final rule, if during
all of that period the management of the entity made a good faith effort to
operate it as a provider-based facility or organization.
Good Faith Effort
HCFA determines that the management of a facility has made a good faith effort
to operate it as a provider-based entity if:
- The requirements regarding licensure and public awareness are met;
- All facility services were billed as if they had been furnished by a department
of a provider, remote location of a hospital, satellite facility, or a provider-based
entity of the main provider; and
- All professional services of physicians and other practitioners were billed
with the correct site-of-service indicator.
INAPPROPRIATE BILLING
The final rule outlines the actions that will be taken by HCFA where inappropriate
billing has occurred or is occurring after a non provider-based determination
has been made.
Notice to Provider
HCFA will issue written notice to the provider. The notice will inform the
provider that payments for past cost reporting periods may be reviewed and recovered
and that future payments will be adjusted.
Adjustment of Payments
Future payments will be adjusted to approximate as closely as possible the
amounts that would have been paid, in the absence of a provider-based determination,
if all other requirements for billing were met.
Review of Previous Payments
Previous payments will be reviewed and, if necessary, action will be taken
in accordance with the rules on inappropriate treatment of a facility or organization
as provider-based.
Determination Regarding Provider-Based Status
HCFA will determine whether the facility or organization qualifies for provider-based
status. If it is determined that the facility or organization qualifies for
provider-based status, future payment for services at or by the facility or
organization will be adjusted to reflect that determination. If the facility
or organization does not qualify for provider-based status, future
payment for services at or by the facility or organization will be made accordingly.
CONTINUATION OF PAYMENT
The notice of denial of provider-based status sent to the provider will ask
the provider to notify HCFA in writing, within 30 days of the date the notice
is issued, of whether the facility or organization (or, where applicable, the
practitioners who staff the facility or organization) will be seeking to enroll
and meet other requirements to bill for services in a free-standing facility.
If the provider indicates that the facility, organization, or practitioners
will not be seeking to enroll, or if HCFA does not receive a response within
30 days of the date the notice was issued, all payments will end as of the 30th
day after the date of notice.
If the provider indicates that the facility will be seeking to meet enrollment
and other requirements for billing for services as a free-standing facility:
- Payment for services of the facility will continue, at adjusted amounts
for as long as is required for all billing requirements to be met (but not
longer than 6 months).
- The facility must submit a enrollment application and provide all other
required information within 90 days after the date of notice and furnish all
other information needed by HCFA to process the enrollment application and
verify that other billing requirements are met.
- If the necessary applications or information are not provided, HCFA will
terminate all payments to the provider as of the date HCFA issues notice that
necessary applications or information has not been submitted.
OTHER ISSUES
Correction of Errors
HCFA may review a past determination of provider-based status if it believes
that the determination may be inappropriate. If HCFA determines that a previous
determination was in error, and the entity should not be considered provider-based,
HCFA notifies the main provider. Treatment of the facility or organization as
provider-based ceases with the first day of the next cost report period following
notification of the redetermination, but not less than 6 months after the publication
of the Final Rule.
FQHC Facilities
FQHCs that have furnished services that were billed as if they were a department
of the provider, for at least 5 years prior to the issuance of the Final Rule,
will continue to be treated as a department of the provider without regard to
the provider-based criteria.
This provision applies to FQHCs that received a grant before 1995, is receiving
funding under a contract with the recipient of a grant, or based on the recommendation
of the public health service, was determined by HCFA before 1995 to meet the
requirements
Indian Health Services (IHS) and Tribal Facilities
IHS or tribal facilities will be considered provider-based departments of IHS
or Tribal hospitals if on or before April 7, 2000, they furnished only services
that were billed as services of an IHS or Tribal hospital.
PHYSICIAN SUPERVISION REQUIREMENTS
Therapeutic Services
Medicare covers outpatient hospital services and supplies furnished incident
to a physician service. Outpatient hospital services must be furnished:
- By or under arrangements made by a participating hospital, except in the case of an SNF PPS resident
- As an integral though incidental part of a physician's services
- In the hospital or at a location designated by HCFA as a department of a
provider, other than a rural health clinic (RHC) or a federally qualified health center (FQHC).
Partial hospitalization services furnished by a hospital to its outpatients
must meet these "incident to" requirements.
To be covered as incident to physicians' services, the services and supplies
must be furnished on a physician's order by hospital personnel under hospital
medical staff supervision in the hospital, or if outside the hospital, under
the direct personal supervision of a physician who is treating the patient.
For example, if a hospital respiratory therapist goes to a patient's home to
give treatment and no physician accompanies him, the therapist's services are
not covered.
Definition: Direct Physician Supervision
"Direct supervision" means the physician must be present and on the premises
of the location and immediately available to furnish assistance and
direction throughout the performance of the procedure. It does not mean that
the physician must be present in the room when the procedure is performed. The
supervising physician does not have to be of the same specialty as the procedure
or service that is being performed.
Application
The direct supervision requirement is separate from and independent of the
provider-based requirements. Hospitals are already subject to the direct supervision
of "incident to" services requirement per the Medicare Hospital Manual, Pub.
10, Section 230.4A. The Final Rule defines this requirement as it relates to
departments of hospitals.
On Campus Department
For outpatient hospital services furnished in a department of a hospital located
on the campus of the hospital, the direct supervision requirement is assumed
to be met. On the hospital premises, staff physicians are always nearby.
Off Campus Department
When outpatient services are provided at a location off the campus of the hospital,
the physician must be present and on the premises of the location and immediately
available to furnish assistance and direction. This applies to services furnished
at an entity designated as having provider-based status as a department of a
hospital.
Provider Based Entity
The direct supervision requirements do not apply to a provider-based entity, such as a skilled nursing facility
or home health agency, regardless of its location. The "incident to" requirement applies only to hospitals.
Diagnostic Services
In the proposed rule, our model for the physician supervision requirement was
the requirement for physician supervision for diagnostic tests payable under
the Medicare physician fee schedule that was issued in the October 31, 1997
physician fee schedule final rule for CY 1998 (62 FR 59048). There have been
issues raised about the appropriate level of supervision for some specific diagnostic
services. These issues have not yet been resolved.
Hospitals and intermediaries should use to use the October 31, 1997 physician
fee schedule final rule physician supervision requirements as a guide, pending
issuance of updated requirements. Until these are issued, fiscal intermediaries,
in consultation with their medical directors, will define appropriate supervision
levels for services not listed in the October 31, 1997 final rule when the services
are furnished at a provider-based entity in order to determine whether claims
for these services are reasonable and necessary.
SPECIAL RESPONSIBILITIES OF MEDICARE HOSPITALS IN EMERGENCY CASES
When a person comes alone, or with another person, to the emergency department
of a hospital and requests examination or treatment of a medical condition,
the hospital must provide an appropriate medical screening examination, including
ancillary services routinely available to the emergency department, to determine
whether or not an emergency medical condition exists. Existing regulations define
"hospital with an emergency department" to include all hospitals that offer
services for emergency medical conditions, not just those that have organized
emergency rooms or departments.
The intent of the revised regulation is to ensure that patients who come to
the hospital and request examination or treatment for what may be an emergency
medical condition are not denied EMTALA (Emergency Medical Treatment and Active
Labor Amendment) protection simply because they enter the wrong part of the
hospital or fail to make their way to the emergency room. The obligation of
a hospital must be met within the entire hospital. However, provider-based entities,
such as skilled nursing facilities or home health agencies, located off the
hospital campus would not be subject to EMTALA since a patient coming to these
entities would not have come to the hospital.
Definition Change
The phrase, "comes to the emergency department," means that the individual
is on the hospital property. "Property" is defined as the entire main hospital campus, including:
- The parking lot
- The sidewalk
- The driveway
- Any facility or organization determined to be a department of the hospital,
but located off the main hospital campus
- Ambulances owned and operated by the hospital even if the ambulance is not
on hospital grounds
- A non-hospital-owned ambulance on hospital property
A non-hospital owned ambulance off hospital property is not considered to have
come to the emergency department even if a member of the ambulance staff contacts
the hospital and informs the hospital that they want to transport an individual
to the hospital for examination and treatment.
Hospital Responsibilities
If a person comes to an off-campus department of a hospital and requests examination
or treatment of a potential emergency medical condition, the hospital is obligated
to provide the individual with an appropriate medical screening examination
and any necessary stabilizing treatment. In some cases, the patient may need
to be taken back to the main hospital campus for a full screening and or stabilizing
treatment. Under these circumstances, the hospital is responsible for moving
the patient or arranging his or her safe transport.
This principle does not mean the hospital is required to:
- Locate additional personnel or staff to off-campus locations to be on standby
for possible emergencies
- Equip all areas of the hospital to provide emergency care
- Always provide treatment outside the emergency area or department
- Have a fully equipped and staffed emergency department at each location
Protocols
The hospital must establish protocols for the handling of possible emergency
cases at off-campus departments. These protocols must include provision for
direct contact between personnel at the off-campus department and emergency
personnel at the main hospital campus and may provide for dispatch of practitioners
from the main hospital campus to the off-campus department to provide screening
or stabilization services. The intent is to ensure timely exchange of information
between the two sites. These protocols must be established prior to the potential
emergency situation.
While emergency medical services (EMS) personnel can play a valuable role in
transporting patients to appropriate sources of emergency care, they cannot
provide the screening and stabilization needed to fulfill a hospital’s
EMTALA responsibilities. A hospital does not fulfill its EMTALA obligations
merely by summoning EMS personnel. However, EMS may be used appropriately in
conjunction with the hospital’s response.
Department Staffed by Physicians or Nurses
If the off-campus department is an urgent care center, primary care center,
or other facility that is routinely staffed by physicians, RNs, or LPNs:
- These personnel must be trained, and given appropriate protocols, for the
handling of emergency cases.
- At least one individual on duty during the off-campus department its regular
hours of operation must be designated as a qualified medical person (as determined
by the hospital in its by-laws or rules and regulations).
- The qualified medical person must initiate screening of individuals who
come to the off-campus department with a possible emergency medical condition,
and may be able to complete the screening and provide any necessary
stabilizing treatment at the off-campus department.
Other Departments
If the off-campus department is a physical therapy, radiology, or other facility
not routinely staffed with physicians, RNs, or LPNs:
- The department's personnel must be given protocols that direct them to contact emergency
personnel at the main hospital campus for direction.
- Under the direction from the emergency personnel, and in accordance with
these protocols, the personnel at the off-campus department must :
- Describe patient appearance
- Report symptoms
- If appropriate, arrange transportation of the individual to the main hospital
campus or assist in an appropriate transfer
Movement of the individual to the main campus of the hospital is not considered
a transfer, since the individual is being moved from one department of a hospital
to another department or facility of the same hospital.
Transfer Provisions
Hospital protocols must provide for the movement of an individual with a possible
emergency condition to a facility other than the main hospital campus if that
movement is warranted either because:
- The main hospital campus does not have the specialized capabilities or facilities
required by the individual, or
- The individual's condition is deteriorating so rapidly that taking the time
needed to move the individual to the main hospital campus would significantly
jeopardize the life or health of the individual.
The protocols must include procedures and agreements established in advance
with other hospitals or medical facilities in the area of the off-campus department
to facilitate these transfers. A transfer under this provision does need to
meet one of these three existing requirements for transfers:
- The individual, or a legally responsible person, requests the transfer,
after being informed of the hospital's obligations related to emergency cases.
The request must:
- Be in writing
- Indicate the reasons for the request
- Indicate that the person is aware of the risks and benefits of the transfer
- A physician must sign a certification that, based upon the information available
at the time of transfer, the medical benefits of receiving appropriate medical
treatment at another medical facility outweigh the increased risks to the
individual or, in the case of a woman in labor, to the woman or the unborn
child. The certification must contain a summary of the risks and benefits
upon which it is based.
- If a physician is not physically present at the time an individual is transferred,
a qualified medical person (as determined by the hospital in its by-laws or
rules and regulations) must:
- Consult with a physician who agrees with the certification
- Sign the certification containing the same information required for a physician’s certification
The physician must subsequently countersign the certification
