EMTALA claim for failure to provide medical screening dismissed, claim for failure to stabilize medical condition proceeds

Medical screening claims under the Emergency Medical Treatment and Active Labor Act (EMTALA) must assert a failure to screen or improper screening, a district court in Missouri held, granting in part and denying in mart a hospital’s motion to dismiss EMTALA claims. The case was allowed to proceed on the patient’s claim for failure to stabilize her medical condition in violation of EMTALA. The patient’s claims for failure to provide appropriate medical screening in violation of EMTALA and medical malpractice were dismissed (Pennington-Thurman v. Christian Hospital Northeast, October 22, 2019, Cohen, P.).

Procedural history

A patient arrived at the hospital’s emergency department with severe leg cramps, received narcotic pain medication, vomited, and objected to being discharged because she felt ill. The patient was nonetheless discharged and left in the wheelchair in the waiting room. The patient filed a complaint against the hospital and its physician seeking monetary relief for alleged violations of the EMTALA (42 U.S.C. §1395dd) and claims of medical malpractice. The patient claimed the hospital violated EMTALA by failing to: (1) provide appropriate medical screening because they believed the patient lacked health insurance; and (2) stabilize the patient prior to discharge.

EMTALA claims

The hospital moved for dismissal of the patient’s EMTALA claims because the patient failed to plead factual allegations suggesting: (1) she received no screening; (2) she received improper screening for a discriminatory purpose; (3) she received screening that was different from other patients with charley-horse cramps; and (4) she had an emergent condition that the hospital failed to stabilize.

Failure to screen

The hospital argued that the patient’s complaint failed to state a claim for any of the three categories of failure to screen: (1) failure to screen at all; (2) improper screening of patients for a discriminatory reason; (3) and screening a patient differently from other patients perceived to have the same condition. The court held that the patient did not allege that the hospital failed to screen her at all since the complaint’s factual allegations established that the hospital’s nursing staff and physician examined her, performed blood work, and treated her pain. Regarding the second and third categories, the court held that the patient did not allege that patients perceived to have insurance and the same medical condition were screened or treated differently than she was. Moreover, the patient failed to state how the hospital allegedly deviated from its normal screening process. Therefore, the court found that she did not plead facts to support a claim either that the hospital screened her differently from other patients with similar conditions or failed to appropriately screen her for a discriminatory reason. As a result, the court dismissed the patient’s claim that the hospital failed to provide appropriate medical screening in violation of EMTALA.

Failure to stabilize

The hospital argued that the patient failed to state a claim under EMTALA for failure to stabilize her medical condition because the complaint established that the patient treated her emergency medical condition with pain medication and resolved her pain prior to discharge. The court declined to find on a motion to dismiss either that: (1) a reaction to medication that includes vomiting is not an emergent medical condition; or (2) a patient who vomits and feels ill while in the emergency department is stabilized and therefore fails to state a claim under EMTALA. Accepting the allegations in the complaint as true and drawing all reasonable inferences in favor of the nonmoving party, the court found that the patient sufficiently alleged that she had an emergent medical condition and the hospital failed to stabilize her condition prior to discharge. As a result, the court denied the hospital’s motion to dismiss the patient’s failure to stabilize claim.

MedPAC votes to recommend recalculation of MA benchmarks

The Medicare Payment Advisory Commission (MedPAC) unanimously voted to recommend that the HHS Secretary modify the calculation of Medicare Advantage (MA) benchmarks. The recommended change, discussed at the January 12, 2017, MedPAC meeting, would increase spending between $750 million and $2 billion over one year and between $5 billion to $10 billion over five years. Mark Miller, executive director of MedPAC, suggested, however, that previous coding recommendations from the June 2016 report could offset the increased cost.

CMS sets the MA county benchmark based on the average risk-adjusted per capita Part A and Part B fee-for-service (FFS) spending in the county. While this calculation includes all beneficiaries in Part A or Part B, MA enrollees must be in both Part A and Part B. MedPAC policy analyst Scott Harrison noted that 12 percent of FFS beneficiaries are enrolled in Part A only, and Part A-only beneficiaries spend less than half than what those with Part A and Part B spend on Part A. This, he said results in an underestimate of FFS spending compared to MA spending, which leads, in turn, to an understatement of MA benchmarks.

To make calculations more reflective of MA enrollment, the members voted on a draft recommendation, which they also discussed at the December 2016 meeting, that the HHS Secretary should calculate MA benchmarks using FFS spending data only for beneficiaries enrolled in both Part A and Part B.

CMS already adjusts the rate calculation in Puerto Rico so that it is based on beneficiaries who are enrolled in both Part A and Part B. In the April 2016 Announcement of Calendar Year 2017 Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies and Final Call Letter, CMS stated in response to a comment that it would consider expanding this Part A and Part B adjustment to all counties in the future.

At the same meeting, MedPAC also voted to recommend that the Secretary should require hospitals to add a modifier on claims for all surgical services provided at off-campus, stand-alone emergency department facilities. The modifier would allow Congress and CMS to track the growth of off-campus emergency departments, which are reimbursed at higher rates than urgent care centers.