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Based upon observation and interview, the facility failed to ensure the emergency department (ED) posted the required signage specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment of emergency medical conditions and women in labor. Specifically, the facility failed to ensure signs (in a form specified by the Secretary) were posted in places likely to be noticed by all individuals entering the ED; as well as those individuals waiting for examination and treatment.
On 4/2/18 there were no signs observed in the treatment areas, or the entrances to the ED.

Findings included:

EMTALA complaint TX00281222.

Observations on 4/2/18 at 12:30 PM of the hospital's emergency department, with the Executive Director of Emergency Services and the Director of Risk Management/Legal present revealed there were no signs (in a form specified by the Secretary) in the ED's treatment areas or the Entrance areas to the ED (ambulance entrance, outside ED walk in entrance, and entrance from within the Hospital lobby) that specified the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor. This signage was only observed in the Emergency waiting room where individuals sign in requesting services, but not in the treatment rooms or entrance areas to the ED.

During an interview on 4/2/18 at 12:40 PM with the Executive Director of Emergency Services confirmed there were no signs posted conspicuously in the treatment areas or the entrance areas to the ED; (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor.

Review of the facility's ER EMTALA Policy and Procedure last reviewed 11/29/11 indicated the following: 17. Signage: The following language is required by the Health Care Financing Administration to be posted in all public entrances, registrations areas, and Dedicated Emergency Department treatment waiting areas (including separate areas for obstetrics, psychiatry, and urgent care clinics where patients present on an unscheduled basis). "IT'S THE LAW. IF YOU HAVE A MEDICAL EMERGENCY OR ARE IN LABOR, YOU HAVE THE RIGHT TO RECEIVE, WITHIN THE CAPABILITIES OF THIS HOSPITAL'S STAFF AND FACILITIES: AN APPROPRIATE MEDICAL SCREENING EXAMINATION NECESSARY STABILIZING TREATMENT (INCLUDING TREATMENT FOR AN UNBORN CHILD) AND, IF NECESSARY, AN APPROPRIATE TRANSFER TO ANOTHER FACILITY EVEN IF YOU CANNOT PAY OR DO NOT HAVE MEDICAL INSURANCE OR YOU ARE NOT ENTITLED TO MEDICARE OR MEDICAID THIS HOSPITAL PARTICIPATES IN THE MEDICAID PROGRAM."

Based on review of records and interviews, the facility failed to ensure stabilizing treatment for an Emergency Medical Condition (EMC) without regard of the Patient's managed care insurance that was not contracted.

Specifically, Patient #1 came to the Emergency Department (ED) on 8/8/17 with a determined EMC and the ED Physician ordered admit for observation status with intravenous antibiotics. Patient #1 had a Medicare Health Maintenance Organization (HMO) plan from another state, was out of network, and was told that if she was to be admitted; that she would have to transfer to another facility that accepted HMO.
Multiple facility staff continued to discuss the insurance plan, authorization, and coverage with Patient #1 resulting in her discouragement to remain for further treatment and stabilization. Patient #1 left the facility and then returned to the ED on 8/9/17 with continued pain and fever for treatment and stabilization after speaking to her insurance representative who told her that the HMO did not apply because she was out of her home state. Authorization was obtained and then Patient #1 was admitted for treatment and stabilization.

Findings included:

Review of EMTALA Complaint TX00281222 revealed Patient #1 alleged on 8/8/17 she traveled from out of state and went to the hospital's ED after speaking with her Primary Care Physician. Patient #1 indicated she contacted her insurance company (Blue Cross Blue Shield, Health Maintenance Organization) BCBS HMO and received authorization from Representative A; who verified coverage. Following the Medical Screening Examination (MSE), Physician A told her she had an infection and needed to be "admitted" with Intravenous (IV) antibiotics; but that they would not admit Patient #1 at this facility because of her insurance being an HMO plan. Patient #1 indicated that Physician A then told her she only had authorization for Emergency Room (ER) treatment but not for hospitalization; so therefore they would need to transfer Patient #1 to another hospital. Patient #1 stated she tried to explain to the facility that; "it did not work that way; that Blue Cross Blue Shield Medicare Plan will cover," because Patient #1 was out of her home state. Patient #1 stated then another registration insurance expert came in to the examination room and told her they "wouldn't admit me" at this facility. Patient #1 stated she had already signed a waiver upon initial registration that stated she would be responsible for any and all charges that her insurance did not cover, and became "furious" because they would not listen to her about the insurance. Patient #1 stated she left the hospital that night because she was "really upset that their only concern was that they would not collect from my insurance. They were refusing me the medical care that I needed. Because they were more focused on payment instead of patient care." The next morning (8/9/17), Patient #1 called her insurance representative who told her that HMO does not apply to her because she was out of her home state and to make sure the facility knew it was a Medicare Plan and to disregard the HMO part and to bill their local BCBS of Texas. Patient #1 then went back to the ER after speaking to her insurance representative for treatment and stabilization on 8/9/17 with continued pain and fever.

Patient #1 registered on 8/9/17 and Physician B asked her why she left the night before because she needed to be hospitalized. Patient #1 stated she again tried to explain to the registration staff and physician regarding her insurance and they refused to contact the insurance company for coverage/authorization. Patient #1 stated the registration clerk kept telling her that her BCBS HMO was not accepted at this facility and would not acknowledge that is was a Medicare Plan. The registration clerk told her they would have to transfer her to another hospital in another town, or they would admit her under "self-pay." Patient #1 then called her insurance representative again and put them on speaker who directed the facility to "start the process to admit to the hospital."

Review of Patient #1's BCBS BlueAdvantage HMO Medicare Advantage Insurance card issued 12/14/16 indicated, "all urgent and emergent services are covered out-of-area."

Review of Patient #1's Emergency Room Clinical Reports revealed the following completed by Physician A on 8/8/17 at 22:23: 57 year old female Patient (#1) with complaint of "Right Flank Pain and urinary frequency that began last week." Patient #1 with a history of neuromyelitis optica experiencing chronic abdominal pain. Progress and Procedures: Sepsis screen- Positive. Infection suspected. Heart rate greater than 90 (127), Febrile 102.2. Course of Care: Patient #1 with a history of transverse myelitis (rare neurological condition in which the spinal cord is inflamed) on cellcept (Selective Immunosuppressant). 1 gram of rocephin given, urine culture sent. Considering med history admit for IV (Intravenous) antibiotics and observation. Disposition: Observation. Clinical Impression: Acute pyelonephritis (inflammation of the kidney, typically due to a bacterial infection. Symptoms most often include fever and flank tenderness).

Review of Patient (Pt.) #1 notes revealed the following:
On 8/8/17 at 23:59 Pt. pulled out IV and stated that she is going home.
8/9/17 at 00:00 Patient pulled out IV stated, I did it because I am leaving. 4x4 given, patient bleeding, explained to hold pressure to arm where IV was. Female also at bedside, states again, "I'm not staying here."
8/9/17 at 00:09 After conversation had with registration, Pt. became irate, removed IV and walked out. AMA form was not signed.

Review of the form electronically signed by Patient #1 on 8/8/17 during the registration process titled; Non-Contracted Health Insurance Plan, indicated acknowledgement and signature that Patient #1 understood the facility was not a participating provider with Patient #1's health care plan. In the event that payment for services received is denied by Patient #1's health care plan, or processes as out of network benefits, Patient #1 understands that she would be responsible for any and all charges generated by these services.

Review of the Admissions Registrars Notes revealed the following:
8/8/17 Registered patient in office while waiting on room. Per AL (sic) Active BCBS HMO. Scanning in Drivers License and Insurance Card and signed Patient's Bill or Rights. Signature Pad for Conditions of Admission, HIPPA, and non-contracted insurance form. While explaining to Pt that we were not contracted with their Insurance Plan, the Pt called the number on the back of the card for members and spoke with [representative A] about if their visit would be covered or not. Representative A told the pt. that the insurance would cover the cost of the bill. Registrar A informed the patient that we would bill BCBS for the visit and that if their insurance would not cover the visit for any reason then they would be responsible for the cost of the visit. I flagged the tracker and let the ER Physician know.

8/9/17 (2nd ED visit) Entered Pt. room upon Physician B request to explain our HMO policy; she would have to transfer if admitted. Pt stated she spoke to insurance and they said she could stay because she is traveling. Pt became very upset and I explained I could call my boss and see where to go from there. She proceeded to call BCBS. I stepped out of room and re-entered when she had representative on line. Representative was under the impression that we were denying medical attention. I assured representative patient was treated on yesterday and again today. I explained we are not in contract for inpatient/observation. BCBS representative stated he would also be more comfortable with her going to a hospital that accepts HMO policies if she is able to transfer. I explained that I did not know diagnosis but that Physician B verbalized he was ok with a transfer. Representative placed us on hold then stated Pt. could stay at our facility and BCBS would cover costs. Apologized to patient for misunderstandings and let Physician B know she could stay.

8/9/17 Per (sic) Pt will be full admit ERHold. Pt refused transfer and will be staying at this facility. Went to admit Pt with supervisor in order to re-explain HMO waiver.

8/10/17 Called BCBS NTL line and was put through to Regence BCBS of Oregon. Spoke with representative who stated "No authorization required for inpatient" only notification.

RN note 8/9/17 at 21:28 Went into room with registration staff to "verify that patient understood her responsibility to pay for hospital bill in the event that her insurance did not pay any or all of her hospital bill. She responded, "I understand."

Interview on 4/2/18 at 11:50 AM with the Executive Director of the Business Officer stated that once it is determined that a Patients insurance is not contracted, then registration staff have them sign the non-contracted waiver form to warn and tell them that they may be financially responsible if their insurance does not pay for the services/treatment. The ED of the Business office stated that the business office does not get authorization from insurance providers for inpatient admission until the next business day. The ED of the Business office stated that registration clerks do not call and get verification from insurance companies for services; and that is why they just get the patient to sign the non-contracted waiver form in the event the insurance does not cover.

Interview with the Registration Manager on 4/2/18 at 12:15 PM stated her registration clerk- A called her regarding Patient #1's insurance that was not in network and she was presented with a waiver that "she was refusing to sign." The Registration Manager indicated if patients are out of network, then they can be transferred to another facility that is in network. The Registration manager indicated Patient #1 came in late at night and they were not able to verify or get on the phone for authorization of benefits. Registration manager indicated patients with Traditional Medicare can go anywhere and patients with Medicare contracted managed care had rules for coverage. The Registration manager indicated the procedures for registration were completed "bed side" after a patient was checked into a room following triage. The Registration manager stated they get their demographic information, identification, and insurance to verify if they are contracted with this facility for coverage. She further stated that registration staff get the patients to sign consent forms, talk to them about their insurance coverage benefits, and ask for their co-pays. At this time all signatures are done and an HMO waiver signed if needed.

Interview on 4/2/18 at 3:00 PM with Physician A stated Patient #1 was being treated for a kidney infection with antibiotics and fluids, and he recommended admission for observation due to patient #1's use of immunosuppression medications in order to keep her from getting worse. Physician A confirmed Patient #1 had an Emergency Medical Condition when asked; that required treatment and stabilization. Physician A stated he had a conversation with the registration clerk A that Patient #1's HMO insurance may not cover her admission at this facility and he asked the registration clerk A to clarify this concern with her. Physician A stated he had not had a patient with an out of state HMO plan before and that's why he asked registration to clarify. Physician A stated that Patient #1 told him that she had spoken to her insurance, and they told her it would be covered. Physician A indicated if a patient needs admission they could get admitted at this facility or be transferred where it would be covered by insurance. Physician A stated Patient #1 got upset when presented by the registration clerk for clarification, and she left the facility Against Medical Advice (AMA). Physician A stated he did not discharge her, he just wanted clarification because we "would not be able to admit her here, and it be covered by HMO; but could transfer her."

Interview with the facility's Medical Director on 4/2/18 at 3:15PM stated that Physicians do not usually get involved with registration and insurance processes; that should be up to the registration department to handle the financial part. The Medical Director stated there are some known insurance plans that want patients to be transferred; and we give the patient the option to transfer or to be admitted to this facility. The Medical Director indicated physician decisions should not be in regards to insurance coverage.

Review of the facility's ER EMTALA Policy and Procedure last reviewed 11/29/11 indicated; "All individuals who come to the [facility's] Dedicated Emergency Department (DED) and request examination and treatment of a medical condition, whether or not the examination or treatment is explicitly for an emergency medical condition, have a right to receive a medical screening examination and stabilizing treatment. The registration process may be completed using normal DED registration procedures, at any time following the completion of the MSE and the stabilization of the patient, or prior to the MSE and stabilization treatment, if the registration does not interfere with or delay the MSE, patient care, stabilization, or the post stabilization treatment.
The registration process includes the following:
a. Verify all information from the computer system or provided on the forms;
b. Copy front and back of insurance cards, Medicaid, Medicare or other appropriate identification cards;
c. Obtain signature for the financial agreement; and
d. Collect co-payment if applicable.

Review of the facility's policy titled Admission of Patients to the Emergency Department, last reviewed 3/13/18 revealed "At no time will treatment be delayed for the purpose of obtaining demographic or insurance information."