Transfer Requests at the Intersection of EMTALA

Physician advisors can serve as a trusted resource for any EMTALA concerns.

Physician advisors have numerous roles in their organizations. These roles focus on medical necessity, length of stay, utilization review (UR), and efficient delivery of healthcare. Transfer centers can be a significant entry point into healthcare organizations, and oversight by physician advisors is a perfect fit for their responsibilities. 

Involvement of physician advisors in the transfer process will allow an organization to evaluate medical necessity, conduct a financial review, and perform UR prior to acceptance. This process mirrors workflows for admissions coming from emergency departments and should be expanded to include transfer center patients. 

Transfer center requests can be broken down into two categories: ones that fall under the Emergency Medical Treatment and Active Labor Act of 1986 (EMTALA), and those that do not. Transfer requests that fall under EMTALA are commonly from an outside emergency department seeking a higher level of care for a medical condition the sending facility is not equipped to manage. These requests generally do not involve physician advisors, as acceptance is mandated per EMTALA, and no screening or review would be appropriate. However, the physician advisors can serve as a resource for any EMTALA concerns. The sending facility is required to perform a medical screening exam (MSE) and then determine if an emergent medical condition (EMC) exists. 

EMTALA is focused on capacity and capability. If the sending center has no capacity or capability, then EMTALA would be in effect, and if a receiving facility does have both capacity and capability, the transfer would be required to be accepted. There are areas of EMTALA that are vague, regarding what equates to a satisfactory MSE, and if an EMC exists. These are areas in which the physician advisors, with additional training, can serve as a resource for the transfer team and organization. If there are significant concerns regarding a case, it is wise to get risk management involved to review or aid in the decision. One additional note is that patients in observation status are still considered EMTALA cases, and should be approached in that manner. 

Transfer center requests that are not subject to EMTALA are most commonly requests for an inpatient-to-inpatient transfer. Inpatient status generally implies that EMTALA does not apply, but there can be exceptions. These inpatient transfer requests are where the physician advisors will show the most benefit for organizations. There are many healthcare centers that have a “say yes” policy to any request, and this puts them at significant liability for inappropriate transfers. A review of these cases can involve a financial review to ensure an in-network payor, medical necessity, and requested services being available, allowing the physician advisor to conference with specialists about the best treatment plans. Having this oversight and review prior to acceptance allows organizations to minimize out-of-network situations and ensure that services requested meet inpatient criteria. This process involves getting the outside records to review, outside images to be pored over, and the face sheet and insurance cards to perform a financial review. 

This process, however, takes time – but if there is a critical case that needs an expedited decision, the transfer team should reach out to the physician advisor directly for a rapid decision. These inpatient transfer requests are where the physician advisors should focus their efforts – i.e., reviewing the records and gathering any needed information regarding the transfer. 

When performing a review, the physician advisors should be looking to answer several key questions: what is the reason for transfer, what are the capabilities of the sending hospital, is the reason for transfer medically necessary, does this patient still require acute-care hospitalization, are there any red flags on chart review, does this case need specialty consult, and are there any financial team concerns? Common themes that are seen as concerns are lack of guardianship, whether workup can be done as outpatient, lack of ability to get placed at post-acute care facilities, and uninsured or out-of-network payors. It is this review that can address concerns before acceptance and can either deny the transfer or put a plan in place for how to manage the issues before the patient arrives, thus promoting progression of care and shorter lengths of stays. The physician advisors will take all the information they have gathered and then can make educated decisions regarding the transfer requests. 

Transfer centers at large academic centers are typically busy, and have significant call volume that will require a system that is supported by the executive team, with adequate resources. The infrastructure must be able to support a team of specialized nurses, physician advisors, financial counselors, a reliable secure communication system, an electronic medical record with specialized transfer center workflows, and standard expectations of medical staff response times. Integration of the physician advisors into this process will depend on the model and desired involvement from the leadership team. 

Transfer center quality and performance metrics are essential to maintaining a transfer center program. These metrics will show the value of the physician advisor’s oversight role and ensure that the program stays focused on the metrics meeting organizational goals. Common metrics that should be a part of any transfer program include outcomes of requests, reasons for denials, out-of-network payor reductions, time from request to acceptance, call abandonment rates, and a formal review of any deaths occurring within 48 hours of transfer. A team composed of quality nursing, financial advisors, and physician advisors will ensure that a transfer center exceeds the organization’s expectations and goals. 

The return on investment for a transfer center program is substantial when factoring in the reduced out-of-network payor liability, as well as potentially very long-stay patients that might not need to be transferred due to lack of need for an acute-care setting. With physician advisors’ roles so closely aligned with the needs of a transfer center, assuming a leadership role in the transfer center is a perfect fit for physician advisors.