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Sun Aug 26 03:53:29 BST 2007

It is hard to find a happy medium in stopping the practice of transfering minor patients by exploiting loopholes, particularly after the "wallet biopsy." I would offer that facilities that transfer minor patients should not be eligible for reimbursement or billing at all, but then these facilities would compensate by keeping patients with issues well beyond their capability.  The economic damage to patients (without insurance) is extreme. A bill from EMS, another bill form 1st facility and physician, a transfer bill (especially on an aircraft), and bills from the receiving facility and physicians. Might as well have an automatic bankruptcy filing as soon as 911 is called. 

  Some of these transfers man be simply cultural (faster and easier to transfer than to get somebody on call to come in) , or for less malicious reasons such as " I am not comfortable with this treating this patient." 

  What about the issue of free standing EDs? I can bet, if a person with a fx comes in one there is probably not an ortho surgeon there. Mobile ICU or aircraft transfer waiting to happen. I still teach EMS classes, but getting providers to think about "appropriate" facilities is a lost cause. The nearest MD or DO in a building that says "emergency" so a squad can get back in service for the next "big one." trumps all medical care in my experience.

  Mike 

krin135 at aol.com wrote:

Neither states medicaid 
will pay us much of anything because " we are out of state". when we fix the 
usual minor problem and just need placement or something , the referring 
hospitals refuse? to take pt back, as "they dont have insurance and we cant get 
paid.? It is really becoming a burden on the trauma centers.

Dr. Wolfer:

Something that we did in the 'border parishes' of Louisiana was to apply for Arkansas, Mississippi or Texas (depending on the location) Medicaid provider numbers. Since these were in an underserved area, and many patients came to us for care because there was no closer 'in state' facility, we had at least the basic Medicaid payment for re imbursment.

I believe that there are some hospitals in Missouri with similar situations who have done much the same thing in regards to Arkansas and Tennessee.

ck
Charles S. Krin, DO FAAFP

-----Original Message-----
From: rwolfer at aol.com
To: trauma-list at trauma.org
Sent: Sat, 25 Aug 2007 8:05 pm
Subject: Re: Avoiding EMTALA (...and Crossposted)

InWV we see it all the time, even with Drs on call in specialty at referring 
hospital.? It is more common after the "wallet biospy". they all claim the the 
pt with fracture is trauma ( isloated fracture) and must go to trauma center. If 
pt has insurance they never seem to send it but take care of it themselves. As 
we are a tristate area we? also get pts from KY and OH. Neither states medicaid 
will pay us much of anything because " we are out of state". when we fix the 
usual minor problem and just need placement or something , the referring 
hospitals refuse? to take pt back, as "they dont have insurance and we cant get 
paid.? It is really becoming a burden on the trauma centers.

Rebecca Wolfer, MD, FACS, FCCP
Associate Professor, Marshall University School of Medicine
Dept of Surgery
Director Thoracic Surgery
Director, Surgical Critical Care Cabell Huntington Hospital
Director, Trauma Cabell Huntington Hospital

-----Original Message-----
From: KMATTOX at aol.com
To: SURGINET at listserv.utoronto.ca; trauma-list at trauma.org
Sent: Sat, 25 Aug 2007 12:51 pm
Subject: Avoiding EMTALA (...and Crossposted)

I had the in house acute care surgery and trauma call last night. Between 
responding to more than 15 code 2 & 3 trauma activations, 5 operations, 
continuing my week long www research into cross posting, I received more than 
half 
a dozen calls from area hospitals, some of them quite large. I had very 
pleasant discussions with the emergency room physicians and we had both 
clinical and "their backup" type discussions. We talked about the management 

of 
the clinical conditions. And YES, I accepted all of the patients. My 
first response was, "Yes, I am going to accept your referral, now let's talk 
about the patient and anything else you wish to talk about." I did this even 
though we were quite full, because both the patient and the calling doctor was 
not the ones responsible for the predicament they found themselves in. 
Each of the emergency doctors were surprised I just accepted the patient up 
front so readily. I did tell them, that if we found that the condition was 
of 
a very minor nature, I would give them a call back and we would discuss what 
they could have done at their local ER. 

At issue here is an INCREASING practice of emergency departments and backup 
specialty call. Apparently Texas hospitals have discovered that there is a 
loophole in the EMTALA law which states that if a hospital has specialists 
on the staff, but because of the number of specialist, it would be a burden 
for them to be on excessive numbers of call nights, then the call roster will 
just be empty or devoid of a name for that specialty for that night. The 
doctors last night told me that some nights they have NO names on any of their 
call rosters and on NO night is there at least 1-3 empty spaces. EMTALA 
then stipulates that although the hospital has a specialist on the medical 
staff, they do not have a duty to call in that specialist unless her/his name 
is 
on a call roster. 

None of the cases last night were immediately life threatening. The patient 
conditions (among others) included: corneal abrasion, fractured pelvis, 
painful abdomen (LLQ) and WBC of 19,000 with suspected diverticulitis, and 
multiple different hand trauma calls. I have discovered that for more than 
70% 
of the time, the BTGH is the only hospital with a "hand surgeon" on the call 
roster in a 9 county area, whether or not the patient has a funding source. 
I encountered for the first time a very interesting mechanism for transfer. 
The patient with the acute abdomen who I readily accepted in transfer, was 
checked out by the sending doctor, and then the registration area of the 
emergency room arranged the transfer. They gave him a printed copy of a 
MapQuest route to get to our hospital. 

This is not a new problem and we have been addressing it in open and 
regulatory forums (we being the hospital administration and the regional trauma 

council, etc.). Apparently, this is allowable by EMTALA. My reason for 
this 
post is to alert each of you to this practice and to ask about its 
prevalence. 

Ironically, it is used MORE in patients with no resources. 

I am crossposting because this issue has significant interest to both groups 
and according to my research is totally within the etiquette of the 
Internet. 

k

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Avoiding EMTALA (...and Crossposted)