Silent denials... what you don’t know hurts the patient experience and your bottom line

Part 1 of 3: Testing your patient transfer policy... The first 3 of 9 critical questions, and answers (6 minute read).

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It’s a busy day. Your meeting count is the same as usual... heavy. Not for any reason other than there are simply no more open slots on your calendar. You’re moving through your day and catch a break. Your late morning meeting ends early. You head back to your office to catch up on email and your phone rings.

It’s a leader from another hospital in your community. She wants to transfer a patient to your facility because they aren’t equipped to provide the necessary care. Because it’s your mission to serve the healthcare needs of the people in your community, you agree to the transfer. 

After connecting her to the right team member for processing the transfer, you hang up the phone. But after this call, you don’t move on. You pause because it suddenly occurs to you that the transfer from last month resulted in a series of uncovered, denied, and ultimately unpaid claims totaling 500,000.

That time everything appeared to be right, on the surface anyway. But it ended badly from a financial perspective for both your bottom line and the financial part of the patient experience. Will this one end the same?

If you haven’t personally experienced this scenario, you probably know someone who has. And while it may seem obvious, simply having a transfer policy doesn’t equal protection from the scenario you just read. It happens often... too often.

When was the last time you reviewed your transfer policy? If you don’t know, don’t wait until the next transfer happens. Prevent this seemingly silent denial before it slips in through the back door of your hospital. So let’s pull out (and dust it off if it’s been more than a year) your transfer policy and put it to the test. Here are 9 questions (and answers) to use. 

 

1) Where will the patient arrive at your facility?

Will the patient be directly admitted to the floor or will they come through the ED? Which is better? Does it even matter?  Does EMTALA apply to the transfer? Ok that’s more than one question, but they are all tied together in thought!

The most important part of this question is whether EMTALA applies to the transfer.  EMTALA is applicable to transfers and governs how patients may be transferred from one facility to another facility. Under federal law, a patient is considered "stable for transfer" if the treating physician at the originating facility determines no material deterioration will occur during the movement (transfer) between facilities and that the receiving facility has the capacity to manage the patient's medical condition. EMTALA does not control the transfer of stable patients; however, patients with incompletely stabilized emergency medical conditions still may be transferred under EMTALA if one of two conditions exists, as follows:

  1. The patient (or someone acting on the patient's behalf) provides a written request for transfer despite being informed of the hospital's EMTALA obligations to provide treatment.
  2. A physician certifies that medical benefits reasonably expected from transfer outweigh the risk to the individual.

Where the patient arrives at your facility has no impact on whether EMTALA applies or not. Most facilities will accept transfer through the Emergency Room because they are set up to receive patients from external sources, where the ICU or CCU floors may not.  The ED is also logistically located in a manner to allow discharge from the helicopter, ambulance or other transport. The hospital may also choose to receive patients in the ED so they can stabilize them before sending them to the floor or operating room.   These may all be strategic reasons to receive transfers through the ED, but it is not required.

 

2) What information is collected before the transfer arrives? Can the transfer be authorized?

Once a decision is made to transfer the individual, the following steps must be taken:

  1. The transferring hospital must provide all medical treatment within its capacity, which minimizes the risk to the individual's health.
  2. The receiving facility must accept the transfer and must have space available and qualified personnel to treat the individual.
  3. The transferring hospital must send copies of all medical records related to the emergency medical condition. If the physician on call refuses or fails to assist in the patient's care, the physician's name and address must be documented in the medical records provided to the receiving facility.
  4. Patient demographics and insurance information if available  will also allow the registration staff to get a head start on the plan benefits although entrance via the emergency room will never require an authorization under these circumstances.

 

3) Who at the hospital should authorize a transfer? Is it a clinical decision, financial decision, operational decision or a combination of all three?

The discussion in the interpretive guidelines and case law obligate a hospital to accept an unstable patient if it has the capacity and has any equipment that the patient's condition requires that the referring hospital lacks. This disproportionately expands the obligations of EDs with more sophisticated capabilities, and increases the obligations placed on on-call physicians. Although EMTALA obligates hospitals to have a roster of on-call physicians who can complete medical screening examinations and provide stabilization for the services the hospital offers to its community, many hospitals are not able to fill their on-call rosters. A recent decision by a Federal appeals court concluded that a patient coming to the ED triggers EMTALA obligations not only when the patient is on hospital property, but also while traveling toward the hospital. So, even when the decision to divert ambulance patients is reasonable, the ED may still be liable for EMTALA violation.

 

Ok, that’s a wrap for today’s post. Stay tuned for part 2 of 3 covering the next 3 questions and answers of 9 in testing your patient transfer policy:

  • Who is responsibile for the care of the patient in transit?
  • Who gets the bill for service in the ED?
  • When do you say no to a transfer?

Disclaimer: this document is a summary perspective of the guest author. It does not represent a formal legal interpretation by the author or MedAssist.


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ABOUT THE AUTHOR:

Keith is a nationally recognized healthcare financial and compliance expert with over 30 years of healthcare experience. He began his career as a trauma nurse before transitioning to the financial and compliance areas of healthcare. With this unique combination of clinical, operational, compliance and financial expertise he has advised hundreds of healthcare providers across the nation. 

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