Case Review Connections

Medical Director's Corner

Written by Jessica Whitley, MD, MBA

The Emergency Medical Treatment and Labor Act (EMTALA) Department at Acentra Health plays a pivotal role in ensuring that hospitals adhere to federal mandates requiring the provision of emergency services to all individuals, regardless of their ability to pay. Between May and July 2024, the department reviewed 153 EMTALA cases, with significant issues identified in 67% of these cases.

A primary area of concern was inappropriate medical screening exams (MSEs). The importance of thorough and accurate MSEs cannot be overstated, as they are crucial in promptly identifying and addressing emergency medical conditions.

Psychiatric Concerns in Emergency Settings

One of the most alarming trends identified by the data is the prevalence of psychiatric issues in EMTALA cases. These concerns constituted 20% of the reviewed cases, with 90% of these psychiatric cases revealing significant care issues. This finding highlights the growing challenge of managing mental health crises in emergency departments (EDs). In the cases where an EMTALA physician reviewer identified an issue with the care, 43% of patients had suicidal ideation as the primary psychiatric concern.

Opportunities for Improvement in Psychiatric Care

The trends observed in the EMTALA reviews underscore the urgent need for improving psychiatric care in EDs. According to the Agency for Healthcare Research and Quality (AHRQ), mental health and substance abuse complaints now account for one in eight ED visits, totaling nearly 12 million visits annually. Despite these alarming statistics, ED staff frequently report feeling ill-equipped to address the needs of patients with mental health issues. Providers may find this Suicide Assessment Card regarding suicide published by the United States Department of Health & Human Services Substance Abuse and Mental Health Service Administration useful. For more information, visit our EMTALA page.

EMTALA Poster

The Centers for Medicare & Medicaid Services (CMS) released an updated poster on August 13, 2024, for hospitals to display, informing patients of their rights under EMTALA. This poster should be placed in EDs and areas where patients might be treated or wait for treatment. The poster also includes information on how to file a complaint if patients believe their rights have been violated. Hospitals are encouraged to use this new poster to meet CMS requirements. The poster can be found in the “Downloads” section of the CMS EMTALA  page.

Appeals Reminder - Safe Discharges

What are the key factors you are looking at for a safe discharge plan? 

Key considerations for a safe discharge plan:

• Secure a skilled nursing facility (SNF) bed, if applicable.
• If the beneficiary is going home, ensure they can safely return alone.
• Confirm that home health care is arranged.
• Ensure durable medical equipment (DME) is ordered and will arrive before discharge.

All arrangements needed for the discharge must be confirmed and not pending when the appeal is filed.

Transition From Part D To Part B Of Antiretroviral Drugs To Prevent HIV

Recently CMS advised pharmacies and other stakeholders to prepare for the upcoming shift in coverage for HIV prevention drugs (pre-exposure prophylaxis, or PrEP) from Medicare Part D to Medicare Part B. This change took effect in late September 2024 once the final National Coverage Determination (NCD) was released. More details about this transition can be found on the CMS website under PrEP for HIV & Related Preventive Services.

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