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and need emergency care (e.g., an individual
who collapses in the hospital parking lot).
to the emergency department” when the
individual is “on hospital property.” 6 The
manual defines “hospital property” to include
when they had more information about the
suspected abortion. In the second conversation,
the ED physician inquired as to whether
The EMTALA regulations apply different standards
to individuals in ambulances (ground
and air) based upon whether the hospital owns
the ambulance. If an ambulance is owned by a
hospital, EMTALA applies to an individual in
the ambulance (regardless of the ambulance’s
location), unless the ambulance is operated
under communitywide emergency medical
service (EMS) protocol (and the EMS protocol
directs the ambulance to another hospital).
hospital-owned ambulances, thereby making
EMTALA apply to individuals in hospitalowned
ambulances. In contrast, the manual
states that an individual in “a non-hospital
owned ambulance not on the hospital’s
property is not considered to have come to
the hospital’s emergency department”.
CMS’ interpretation of the “comes to the
emergency department” threshold creates a
bright–line in the context of individuals in
the patient had medical coverage, and when
the paramedics gave no assurance of coverage,
he abruptly terminated the call (an action
that the paramedics interpreted as requiring a
diversion of the patient to another hospital).
The patient brought a personal injury
lawsuit against the hospital, alleging that the
hospital violated EMTALA by diverting her
ambulance to another hospital. The trial court
ruled in favor of the hospital on the basis that
If an ambulance is not owned by the hospital,
then EMTALA applies to an individual in the
non-hospital ambulance once the “ambulance
[is] on hospital property.” To emphasize
that the ambulance must be on the hospital
property in order for EMTALA to apply, the
regulation specifically states that an individual
in a non-hospital ambulance that is not on
hospital property is not deemed to have
come to the ED. However, an individual in a
non-hospital owned ambulance off hospital
property is not considered to have come to
the hospital’s emergency department, even if
a member of the ambulance staff contacts the
hospital by telephone or telemetry communications
and informs the hospital that
they want to transport the individual to the
hospital for examination and treatment. 5
ambulances: EMTALA applies to individuals
in hospital-owned and controlled ambulances
(unless an EMS protocol applies); and
EMTALA does not apply to individuals in a
non-hospital ambulance until the ambulance
is on hospital property.
Courts’ view of EMTALA
In April, 2008, the US Court of Appeals
for the First Circuit issued an opinion
that found that an individual can allege
a violation of EMTALA when a hospital
diverts a non-hospital ambulance that is not
on hospital property to a different hospital
because the patient is uninsured. Morales v.
Sociedad Española De Auxilio Mutuo Y
Beneficencia, 524 F.3d 54 (1st Cir. 2008).
In that case, the plaintiff had an ectopic
the patient had not “come to the ED,” and
thus the hospital’s duties under EMTALA had
not been triggered. The US Court of Appeals
for the First Circuit, in a 2-1 decision,
reversed the trial court ruling.
The First Circuit concluded that for
EMTALA to apply, the plaintiff must “come to”
the ED. The First Circuit noted that the statute
did not provide a definition for that term, and
concluded that the term itself was not selfelucidating.
As such, the First Circuit looked to
CMS regulations for guidance. The First Circuit
found the regulations to be ambiguous on the
basis that the regulations do not state “whether a
hospital may divert an approaching ambulance
only when it is in diversionary status, or whether
it may do so under other circumstances.” 7
The First Circuit also found the CMS State
CMS’ interpretation, that an individual in an
non-hospital ambulance has not “come to”
the ED until the ambulance is on hospital
property, has a common-sense appeal—a
hospital cannot provide a screening exam or
stabilizing treatment to an individual that is
not at the hospital.
pregnancy and began experiencing severe
abdominal pain while at work. She was placed
in an ambulance that set off for the defendant
hospital. The ambulance was not owned by
the hospital, and the paramedics who manned
it were not hospital employees. While in
transit to the hospital, the paramedics called
ahead to the ED twice. In the first conversation,
Operations Manual guidance to be ambiguous.
By finding CMS’ regulations and guidance to
be ambiguous, the court concluded that there
was no clear interpretation of the statute upon
which the court could rely.
Ultimately, the court concluded that the intent
behind EMTALA was to ensure that individuals
The guidance issued by CMS in the State
Operations Manual applies a slightly different
analysis to reach the same conclusion. The
the ED physician expressed concern that
the plaintiff might voluntarily have induced
an abortion. He also stated that he was very
were not turned away by hospital EDs on the
basis of their financial status. As such, the First
Circuit ruled that EMTALA would be violated
manual provides that an individual “comes busy and asked the paramedics to call back
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Health Care Compliance Association • 888-580-8373 • www.hcca-info.org
11
October 2008