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Based on medical record reviews, Policies and Procedures reviews, e-mail review, BHI (Broward Health International) (Name of Insurance) Verification Matrix", Incoming Referral (Referral and Response) form review, On- Call schedules review, and interviews it was determined the facility refused to accept, from a referring hospital (Hospital B) within the boundaries of the United States an appropriate transfer of an individual who required such specialized capabilities or facilities (Neuro-surgery- surgery performed on the nervous system, especially the Brain and spinal cord) Hospital A (Broward Health Medical Center ) had the capability to treat Patient #1 of 20 sampled patients medical records reviewed. A request was made form Hospital B to transfer Patient #1 to Hospital A due to the patient requiring a higher level of care for am identified emergency medical condition. Hospital A declined accepting the patient due insurance reasons. The patient needed emergent transfer to a facility that had neurosurgical capabilities that were not available at Hospital B.


Cross refer to Tag A-2411.

Based on medical record reviews, Policies and Procedures reviews, e-mail review, BHI (Broward Health International) (Name of Insurance) Verification Matrix", Incoming Referral (Referral and Response) form review, On- Call schedules review, and interviews it was determined the facility refused to accept, from a referring hospital (Hospital B) within the boundaries of the United States an appropriate transfer of an individual who required such specialized capabilities or facilities (Neuro-surgery- surgery performed on the nervous system, especially the Brain and spinal cord) Hospital A (Broward Health Medical Center ) had the capability to treat Patient #1 of 20 sampled patients medical records reviewed. A request was made form Hospital B to transfer Patient #1 to Hospital A due to the patient requiring a higher level of care for am identified emergency medical condition. Hospital A declined accepting the patient due insurance reasons. The patient needed emergent transfer to a facility that had neurosurgical capabilities that were not available at Hospital B.

The findings included:

The hospital's policy and procedure, titled, GA-029-020 Transfer, documented within the Policy, in part, the following, "Transfers of all Emergency Department patients must follow the Emergency Medical Treatment and Labor Act (EMTALA) ... and Federal EMTALA laws require hospitals to accept ED to ED transfers from another facility any patient when the following four criteria are present, It is the policy of Broward Health that requests for ED-to-ED transfers shall be accepted by Broward Health's hospitals. i. The patient is suffering from a documented emergency medical condition. ii. The patient requires specialized treatment to stabilize his/her condition. iii. The transferring hospital lacks the service capability and/or capacity to provide the specialized care and iv. The receiving hospital has the necessary service capability and capacity" and in Procedure "The Broward Health Patient Logistics Center Registered Nurse will process all requests in the following manner ... Emergent ED to ED transfers will be accepted if Broward Health has capacity and capability without regard to patient's ability to pay following EMTALA guidelines."

The hospital's policy and procedure, titled, GA-015-010 - Global Operation Process for International Patients, documented, in relevant parts, the following,
"An International Patient is defined as: Any funded (non-charity) patient (regardless of nationality) located outside the continental United States seeking care at Broward Health ...";
Under Policy, the following, "Requests for referral of international patients will be processed using the procedure below";
Under Procedure, the following, "A request for services from a number of different sources may be received by Broward Health Global Operations... 2. Service requested as well as patient's demographics, clinical and insurance information are obtained from the inquiring party. 3. BHI [Broward Health International] Global Operations Transfer Team evaluates the request and proceeds to approve or deny the case. BHI Global Operations Manager may contact executive management for decision-making as needed."


A review of the facility's Specialty On-Call schedule revealed that a Neurosurgeon (Capability) was on call on May 14, 2024, when the request was made to transfer Patient #1 Hospital A. There was no documentation in the medical record to indicate the Neurosurgeon on- call was notified of the transfer request for Patient #1.

Review of Hospital B's record documented Patient #1 presented to the ED on 05/14/24 at 10:00 AM with chief complaint of new onset of inability to walk (paraparesis) and sacral pain. Review of Hospital B's Physician Assessment and Certification documented Hospital A was contacted for possible transfer and was unavailable to accept Patient #1 at this time. Review of the Patient Data Report documented Patient #1 was alert and oriented, was stable for transfer, and left Hospital B on 05/15/24 at approximately 10:42 PM for transfer to Hospital C.


Review of Hospital B's Physician Assessment and Certification documented Hospital A was contacted for possible transfer and was unavailable to accept Patient #1 at this time. Review of the Patient Data Report documented Patient #1 was alert and oriented, was stable for transfer, and left Hospital B on 05/15/24 at approximately 10:42 PM for transfer to Hospital C.

Patient #1's hospital record from Hospital B documented in the findings for the CT (computed tomography) scan of the lumbar spine that there is an L2 (2nd lumbar spinal vertebrae) pathologic compression fracture (break in the bone caused by underlying disease) with retropulsion (posterior displacement of a fracture fragment into the spinal canal) and critical central stenosis (severe narrowing of the spinal column with pressure on the spinal cord); multiple lytic lesions of bone (areas of bone destruction) consistent with widespread bone metastasis (secondary cancerous growths) versus multiple myeloma (a cancer of the blood). The record documented under Plan, "This pt (patient) needs emergent jet transport to a neuro surgical facility as this is not available at this facility at this time... Will also need oncologists work/up...possible radiation Tx (treatment) as this is also not available at this facility at this time..."
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Review of the Hospital A's documentation for Patient #1's incoming referral (Referral and Response) form, created 05/14/24 at 12:30 PM by Transfer RN (Registered Nurse), Staff B, revealed the following: Patient #1 was referred by a hospital's Emergency Department (ED) in the U.S. Virgin Islands (a United States territory) for "Oncology" service. The referring physician was identified as Physician A, who was employed by this (Hospital A) hospital, rather than the referring hospital (Hospital B); that "no physicians have been contacted"; and the Case Disposition was documented as "Declined - Insurance Reason" on 05/14/24 at 12:36 PM.

Review of emails attached to the preceding case information revealed on 05/14/24 at 12:34 PM, a Medical Social Worker from Hospital B emailed the hospital's Transfer RN (Registered Nurse), Staff B, that medical records for Patient #1 were attached and explained Patient #1 presented to the ER (Emergency Room) unable to walk and in severe pain, was found to have new onset of paraparesis (loss of voluntary motor function in the legs) due to acute (recent) displaced fracture in the lumbar spine resulting in severe critical stenosis and he may also have metastatic prostate cancer or multiple myeloma. The emailed response from Staff B on 05/14/24 at 12:35 PM documented, "As of April 1, 2024, Broward Health is no longer in network with (name of Health Insurance Plan). Unfortunately, we will not be able to accept this case at this time unless the patient has another insurance plan that is in BHMC's [Hospital A] network. Please advise how you would like us to proceed."


During an interview on 06/04/24 at 9:25 AM, the Director of Patient Logistics reported the Transfer Center only handles transfers within the 48 continental states and does not handle any transfers, including ED to ED transfers, for U.S. territories.

During an interview on 06/05/24 at 1:33 PM, Transfer Nurse, Staff B, confirmed she had declined the ED to ED transfer request for Patient #1 and explained in doing so, she followed the "matrix" for insurance verification, that directed to decline patients with certain payor sources, including insurance companies with which they are not contracted unless they also have another acceptable payor source, and she has never had a situation or exception to that. Staff B stated she and her coworkers in the Transfer Center did not know until the last few days that the Islands which are U.S. territories are subject to EMTALA requirements for transfers.

Review of the "BHI (Broward Health International) (Name of Insurance )Verification Matrix" documented in red letters "Decline" for (Name of Hospital Health System) Insurance, (Name of Health Insurance), and "Non-Contracted Insurance Policies", which was followed by "The following insurance companies are not accepted" and a list of insurance companies. Nowhere on the Matrix does it document exceptions for any patients outside the continental United Stated but in U.S. territories seeking an appropriate emergency transfer under EMTALA regulations.

During an interview on 06/04/24 at 1:18 PM, the Medical Director of International Services confirmed it would have been an appropriate transfer to get Patient #1 to neurosurgery; that if the requesting facility [Hospital B] had called back after the email and said this is an emergency, the Transfer Nurse would have called her (the Medical Director) and she would have looked at it deeper. The Medical Director of International Services also stated Patient #1 needed somewhere with the specialty, but it was not for emergency surgery that day. She stated it seemed to her that it was more urgent and not an emergent transfer; that they could have said yes but then after Patient #1 was further stabilized here (Hospital B), he would have to go to another hospital where he had coverage and then he would still be stuck with the bill. She explained they are thinking of what is best for the patient and if it was not for that issue, they (Hospital A) could have taken him and they could take care of him. The Medical Director of International Services stated, "If we can provide the service and it wouldn't be a financial burden for the patient or us, that would be the consideration."


The facility failed to ensure that their own policy and procedure was followed as evidenced by refusing to accept Patient #1 without regard to his ability to pay following EMTALA guidelines as stated in the policy. On May 14, 2024, Patient #1 had an identified emergency medical condition, and required the specialized care of a Neurosurgeon, the transfer was declined due to insurance reasons. Hospital B had the capability to provide the needed care for patient #1.