EMTALA: your right to emergency care and what insurers cannot deny

What EMTALA requires

Any hospital that participates in Medicare and operates an emergency department must provide a medical screening exam to anyone who comes to the ED, regardless of ability to pay or insurance status.

If an emergency medical condition exists, the hospital must either stabilize the patient or arrange an appropriate transfer.

Source: 42 USC 1395dd. See https://www.law.cornell.edu/uscode/text/42/1395dd.

EMTALA and prior authorization

EMTALA prohibits hospitals from delaying screening or stabilizing treatment to inquire about insurance status or to seek prior authorization.

An insurer cannot retroactively deny emergency services on the ground that the patient should have gone to a different facility — the prudent layperson standard at 42 USC 1395dd(e)(1) governs.

How EMTALA interacts with the No Surprises Act

The No Surprises Act builds on the prudent layperson standard. Out-of-network emergency services must be covered at in-network cost-sharing, with balance billing prohibited.

Source: https://www.cms.gov/nosurprises.

What to do if a denial cites prior auth or out-of-network

Quote the prudent layperson definition in your appeal. If the symptoms at presentation could lead a reasonable person to believe an emergency existed, coverage applies.

Attach the ED record, triage notes, and the discharge diagnosis. The screening and stabilization phase is what matters, not the final diagnosis.