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Based on observation, interview, and record review, the hospital failed to ensure that one of 20 sampled emergency department (ED) patients was not unduly discouraged from remaining for further evaluation during their registration process when they were told that the physician portion of their ED bill would not be covered by insurance. (Patient 17) Patient 17 did not receive a medical screening evaluation and did not sign a written informed refusal. This failure had the potential for an emergency condition to not be identified in a timely manner and thus potentially resulting in patient decline, including death.

Findings:

On 11/10/14, Patient 17's record was reviewed. Patient 17 presented to the emergency department on 11/1/14 at 10:14 am with shortness of breath. Patient 17's record contained no evidence of a medical screening examination or any further care, and documented that Patient 17 left without being seen by a physician at 10:17 am. Patient 17's record contained documentation of a follow-up phone call to Patient 1 made by the ED Manager which read, "Per pt (Patient 17), "The lil' (little) lady at the front desk told me the ED dr's (doctors) don't take Medicare or my AARP secondary so I went to (another facility 36 miles away). They told me that I have pneumonia and put me on a bunch of meds (medications). I thought I was going to die on that drive to (neighboring town 36 miles away)."On 11/10/14 at 10:30 am, Patient 17's family member (FM) was interviewed. FM indicated that he was present the entire time with his wife and related the following, "After getting the basic registration information, the ED clerk stated she had to inform us that the hospital portion of the billed charges would be covered by Medicare and their secondary insurance but the physician's component would not be covered and they would have to pay the full charge." FM stated they chose to leave because they were concerned that they might have to pay a large unknown sum that they could not afford. FM reported that Patient 17 was not seen by a nurse or a physician, or offered a transfer or an informed refusal form. FM stated that his wife was so sick that he knew he had to get her to a doctor right away. On 11/10/14 at 3:20 pm, the registration area was observed to have a sign directly behind the registration clerks head which read, "Attention Emergency Room Patients - Due to circumstances beyond the control of (hospital) the emergency room physicians are not contracted with any insurance companies at this time. In addition, the emergency physician charges are billed separately from hospital charges. The patient is financially responsible (will be billed later) for the emergency department physician charges. We are sorry for the inconvenience this may cause you. Administration of (the hospital)."On 11/10/14 at 2:45 pm, ED clerk denied she had spoken to Patient 17's family about insurance coverage. Later in the same interview, ED Clerk said that Patient 17 had asked about her insurance coverage and she stated she told them the hospital was covered but could not recall if she talked to them about the physician coverage. ED Clerk further stated she had been counseled by the CNO regarding the incident and that she reported it was a misunderstanding of her words by Patient 17. ED Clerk related that she was fearful of being terminated.

On 11/10/14 at 3 pm, FM was interviewed again to clarify inconsistencies with the above interviews. FM took exception to the surveyor term "inconsistencies" and stated that he was retired law enforcement and would not have his credibility questioned. FM was asked if there might have been a misunderstanding in what the ED clerk was saying. FM reported that the conversation was short, concise, clear, and was not misunderstood. FM again related the events of Patient 17's time at the ED registration area that matched his previous interview in all details. FM stated that he had not seen the sign posted just behind the registration clerk that informed patients the physicians did not accept any insurance coverage. FM reported that his only concern was getting Patient 17 seen by a physician but he did not want a bill of thousands of dollars that he could not afford. FM further stated that he knew their insurance was accepted at another clinic in (neighboring town 36 miles away) and decided to get Patient 17 there as quickly as possible. FM denied that he was offered to see the physician or sign an informed refusal form prior to leaving. FM expressed concern that the hospital would not want to care for him and Patient 17 in the future based on this event.On 11/10/14 at 3:34 pm, ED Manager stated she has been approached by the ED clerk the following day, and ED Clerk reported that she thought she might have not said the correct thing to Patient 17 when she stated the hospital would accept their insurance but that the physician charges would not be covered.
On 11/10/14 at 2 pm, the Chief Nursing Officer (CNO) stated that she was not aware that physicians were not accepting medicare reimbursement. CNO further stated she had spoken with the ED clerk about the incident because she was concerned there was an EMTALA violation and was told Patient 17 and FM misunderstood. CNO was unaware who had posted the signage at the registration desk.

On 11/10/14 at 1:50 pm, the Controller and the Chief Executive Officer denied knowledge of the sign being posted in the ED registration area and that ED physicians were not accepting Medicare insurance.

On 11/10/14, the hospital policy, titled, "Emergency Care and Transfer," dated 1/31/2004, read, "Emergency services and care will be rendered without first questioning the individual or any other person as to the ability to pay therefore and will not be delayed in order to inquire into the individual's method of payment or insurance status. However, the individual or the individual's legal representative must execute an agreement to pay or otherwise supply insurance or credit information promptly after services are rendered. Under no circumstances shall the provision of emergency services and care be based upon, or affected by, the individual's race, ethnicity, religion, national origin, citizenship, age, sex, pre-existing medical condition. physical or mental handicap is medically significant to the provision of appropriate medical care to the individual. ...No individual who requests services or care may be transferred or discharged from this hospital before emergency services and care are provided."