The Emergency Medical Treatment and Active Labor Act (EMTALA), also known as COBRA to many medical care providers because it was part of the Consolidated Omnibus Budget Reconciliation Act, is a classic administrative law. It was passed in response to a crisis: emergency rooms denying care to indigent patients and private emergency rooms dumping indigent patients onto already overburdened county hospitals. One of the stories that persuaded Congress to act was a nationally publicized effort to find care for a premature infant, including flying the infant around in an air ambulance with nowhere to land. Congress passed the law requiring all persons who presented in the emergency room to be screened and treated, if necessary, and not to be transferred unless it was in the patient’s best interest. The law provides two enforcement mechanisms, private civil litigation (essentially federal law malpractice litigation) and enforcement by the HCFA as part of the Conditions of Participation for Hospitals. Although there has been significant private litigation under EMTALA, the primary enforcement has been by the HCFA. Medical care practitioners must understand EMTALA enforcement because the agency can fine medical care practitioners up to $50,000. Noncomplying hospitals can be fined and banned from participation in federal medical care programs.

There are three appendixes to this section. Appendix 4–A is the EMTALA statute as passed and modified by Congress. Appendix 4–B are formal published regulations promulgated by the HCFA as guidance for hospitals. Appendix 4–C are the guidelines for governmental auditors who actually investigate hospitals to determine if they are in compliance with EMTALA. These documents illustrate the different steps in agency process, from enabling legislation to actual audit guidelines. Ultimately, as is evident from Appendix 4- C, it is only the audit guidelines that really provide the detailed information necessary to know if you are complying with the statute.