The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

Based on the review of facility documents and medical record (MR), and staff interviews (EMP), it was determined that the on call specialist at the facility failed to accept a patient with an unstable emergency medical condition from the transferring facility due to insurance coverage for one of 16 records reviewed. (MR1).

Finding included:

Review of facility policy 'EMTALA" dated December 20, 2012, revealed "...There shall be no delay in providing a Medical Screening Examination or follow-up treatment for an Emergency Medical Condition in order to inquire about the patient's or insurance status...For patients that are enrolled in a managed care plan, prior authorization shall NOT be required or requested before providing an appropriate Medical Screening Examination and/or necessary stabilizing treatment....Individuals enrolled in any managed care plan for which the hospital is not a participant must be screened and treated..."

Review of facility policy "Compliance with Regulatory Requirements for Patients Accessing Emergency Services" revised December 2010 revealed, "...(The facility) is committed to providing medical services to patients regardless of their ability to pay. This is required by Federal law...and is done regardless of authorization by the patient's managed care organization (MCO)...Evaluations and necessary treatment are not withheld pending authorization from a MCO..."

1) Review of MR1 Emergency Department Record dated August 24, 2012, at 11:25 PM revealed, "...Pt has strong preference for Allegheny (out of network hospital) does not want OTH2 (in-network hospital)..."

2) Review of the transferring facility's MR1 Summary Report dated August 25, 2012, at 0153 revealed, "PT TO BE TRANSFERRED TO ALLEGHENY VIA LIFEFLIGHT @ 10 MINUTES. PT AWARE... ." Further review of the MR1's Summary Report dated August 25, 2012, at 0222 revealed "...CALL RECEIVED FROM ALLEGHENY AND THEY WILL NOT ACCEPT PT AS HE HAS (out of network) INSURANCE... ."

3) Review of facility documentation received August 28, 2012, regarding MR1 revealed, "At approximately 0141 hours on 8/25/12, an emergency room physician at OTH3 [transferring hospital] contacted Allegheny General Hospital's One-Call requesting to talk to a general surgeon. The ED MD requested air transport of a patient (MR1) with a perforated ulcer...At 0157, Allegheny's One-Call contacted OTH3 and spoke to the OTH3's ER MD, informing him that the patient had out-of-network insurance. Allegheny's One-Call stated that they would accept the patient but that he might need to be transferred after stabilization (due to out of network insurance)...OTH3's ER MD stated he would speak with the patient...OTH3's ER MD got back on the phone and informed Allegheny's One-Call that the patient preferred to come to Allegheny...At 0208 Allegheny's One-Call spoke with the same surgeon on call (EMP1) for ACS (acute care services) and informed him/her that the patient had OTH2 insurance...EMP1...then revoked acceptance. At 0216, Allegheny's One-Call contacted...on call for the trauma service (EMP28) who stated we can't accept the patient..." The interactions identified above with the transferring facility and Allegheny General One Call were taken from recordings provided to surveyors.

4) During interview on September 13, 2012, at approximately 12:10 PM, EMP1 confirmed the above findings and revealed, "I received a call requesting a transfer of a patient to this hospital. The other hospital was sure they could not stabilize the patient. I thought the best was to transfer the patient. Then I got a call stating the patient had OTH2 insurance. I was not aware of a problem with the patient going to OTH2. I was not aware of EMP28 being called. It was a complete lack of knowledge on my part. I want to follow my patients after surgery, not operate on them and have them be transferred out. I never turned down a patient with the same circumstances... ."

During interview on September 12, 2012, at approximately 11:15 AM, EMP27 revealed "There was a call to EMP1 about a patient with OTH2 insurance. EMP1 had turned the patient down. I said 'no' to the admission since (EMP1) said 'no' and due to the current circumstance with the insurance. For the past 16 to 18 years we were to say yes to all patients. Given the information I was given, I was under the impression I was to say no. Under normal circumstances I would have accepted the patient... "