Special note - What is the 250-yard rule and how does it affect these issues?
The question of what constitutes "coming to the emergency department" is not always a simple one to answer. Over the years, the issue has arisen in connection with the transport of patients by ambulance or by helicopter, the development of a new emergency condition when a patient is already in-house, and similar situations. In 1998, an incident in Chicago raised this issue in a striking way. Allegedly because of a hospital policy prohibiting personnel from leaving the grounds while on duty, emergency room personnel at Ravenswood Hospital failed to provide assistance to 15-year-old Christoper Sercye, who had been shot at a nearby school playground and whose friends had brought him to an alley just off hospital grounds. The boy died from his wounds. The Clinton administration lost no time in announcing its intention to punish the hospital, and reportedly OIG imposed a $40,000 fine, but in truth there was nothing in the hospital's response to this tragic situation which violated the EMTALA rules as they then existed. (This case exemplifies the fact that even a hospital fully in compliance may be subject to a citation and a fine, or worse, if the politics of the situation are wrong -- and if it chooses not to contest the citation. It is only by challenging the citation that the hospital can vindicate itself if the CMS action is erroneous.)
In 2000, CMS issued new amendments to the rules under 42 CFR 489.24, expanding the responsibility of the emergency room to respond to any "presentation" on the hospital campus or at any provider-based off-campus facility of the hospital. In 2003, these rules were significantly revised.
The 250-yard rule comes from the definition of "Campus" found at 42 CFR 413.65:
"Campus means the physical area immediately adjacent to the providerís
main buildings, other areas and structures that are not strictly
contiguous to the main buildings but are located within 250 yards of the main
buildings, and any other areas determined on an individual case basis,
by the CMS regional office, to be part of the providerís campus."
This definition comes into play in connection with the complicated regulations which define "provider-based" facilities.
The significance for EMTALA under the 2000 regulations was that provider-based status was considered to bring some (but not all) off-campus facilities within the sphere of the hospital's responsibility. For those facilities, a patient who presented to a facility requesting treatment, or who appeared and was perceived to be in need of treatment, had to be provided with the medical screening examination prescribed under EMTALA, and provided with stabilizing medical treatment if an emergency medical condition is found.
The 2003 revisions provide:
- A person who presents anywhere on the hospital campus and requests emergency services, or who would appear to a reasonably prudent person to be in need of medical attention, must be handled under EMTALA. Other presentations outside the emergency room do not invoke EMTALA.
- The 250-yard zone will continue to apply when defining the "hospital campus". Now, however, that sphere does not include non-medical businesses (shops and restaurants located close to the hospital), nor does it include physicians' offices or other medical entities that have a separate Medicare identity.
- EMTALA does not apply to any off-campus facility, regardless of its provider-based status, unless it independently qualifies as a dedicated emergency department.