Can a hospital deny you help?

Yes, a hospital can deny you help under specific circumstances, although federal law broadly prohibits denying emergency medical care.

Understanding Emergency Medical Care and EMTALA

Hospitals that participate in Medicare and have emergency departments are generally prohibited by federal law from denying initial emergency medical treatment. This is mandated by the Emergency Medical Treatment and Labor Act (EMTALA), enacted in 1986.

EMTALA aims to prevent "patient dumping," where uninsured or underinsured patients are transferred or refused treatment based on their inability to pay. Under EMTALA, hospitals are required to:

• Provide a Medical Screening Examination (MSE): Anyone who comes to the emergency department, regardless of their ability to pay or insurance status, must receive a medical screening exam by qualified medical personnel to determine if an emergency medical condition exists.
• Stabilize Emergency Medical Conditions: If an emergency medical condition is found, the hospital must provide treatment necessary to stabilize the condition. This means providing medical treatment to ensure that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from the facility.
• Appropriate Transfer: If a patient's emergency medical condition cannot be stabilized at the facility, they may only be transferred to another medical facility if the transfer is appropriate and beneficial to the patient, and the receiving facility has the necessary resources and has agreed to accept the patient.

Specific Circumstances for Emergency Care Denial

While EMTALA broadly ensures access to emergency care, there are very specific and narrow situations where a hospital may have the right to deny or refuse certain services even in an emergency setting. These typically revolve around the absence of a true emergency medical condition as defined by the act, or cases of medical misconduct by the patient:

• Seeking Treatment Primarily for Drugs: A hospital may deny emergency medical care when individuals appear to be seeking treatment primarily to obtain drugs, rather than for a genuine emergency medical condition. This indicates that the primary intent is not for medical stabilization.
• Delusions of Illness: If patients present with delusions of suffering from an illness despite not being medically ill, and there is no underlying emergency medical condition requiring stabilization, the hospital may not be obligated under EMTALA to provide the requested medical treatment for a non-existent physical condition.
• No Emergency Condition Identified: After a proper medical screening examination, if no emergency medical condition is found, the hospital's obligation under EMTALA typically ends. They are not required to provide non-emergency care or admission if the patient does not meet the criteria for an emergency.
• Patient Refusal: If a patient with decision-making capacity explicitly refuses treatment after being informed of the risks and benefits, a hospital cannot force treatment (unless there's a court order or immediate danger to public health, like an infectious disease).

Non-Emergency Situations: When Hospitals Can Deny Care

Outside of emergency situations covered by EMTALA, hospitals have more discretion and can deny care for various reasons. These typically apply to elective procedures, routine appointments, or non-urgent services:

• Lack of Medical Necessity: For non-emergency care, if a physician determines there is no medical necessity for the requested treatment.
• Capacity Limitations: The hospital may be at full capacity, unable to admit new patients, or lack the specialized staff or equipment needed for a specific non-emergency procedure.
• Insurance or Payment Issues: For non-emergency and elective procedures, hospitals can deny service if a patient cannot demonstrate the ability to pay or if their insurance does not cover the service and they haven't made alternative payment arrangements.
• No Established Patient-Provider Relationship: For non-emergency care, a hospital or specific doctor may refuse to accept a new patient or establish a patient-provider relationship, similar to how any business can refuse service unless it's for discriminatory reasons.
• Elective Procedures: Hospitals can deny requests for purely elective procedures (e.g., cosmetic surgery) if they deem it medically inappropriate, if the patient doesn't meet specific criteria, or for other policy reasons.

Your Rights and Recourse

If you believe a hospital improperly denied you emergency medical care, you have rights and avenues for recourse:

• File a Complaint: You can file a complaint with the hospital itself, its patient advocate office, or directly with the Centers for Medicare & Medicaid Services (CMS). CMS is the federal agency responsible for enforcing EMTALA.
• Contact Your State Department of Health: State health departments often oversee hospital licensing and patient complaints.
• Seek Legal Counsel: If you suffered harm due to an alleged denial of care, consulting with a medical malpractice or personal injury attorney specializing in patient rights can help determine if you have a legal claim.

Summary of Hospital Care Denial Scenarios