Question

Case study: Ms. Joan Grant was a 45-year old attorney in private practice. She was enrolled in the Good-Health health maintenance organization (HMO) through her law firm’s self-insured employee benefit plan. Generally she had been in good health, got plenty of exercise, and ate oat bran for breakfast every morning. On the evening of April 15, 2013, while she was rushing to finish her tax return, she developed a splitting headache. She decided that she would have to obtain an extension to file her tax return. Because her doctor’s office was closed for the night, she asked a friend to drive her to the emergency department of Community General Hospital (Community). She arrived at Community at approximately 9:30 p.m. Community is an acute-care general hospital licensed by the state; it participates in the Medicare program. It is owned and operated by General Hospital Corporation, which is a for-profit business corporation. Community has an arranged for 24-hour medical coverage of its emergency department by means of a contract with Village Emergency Physicians, P.A. (VEPPA), which employs Dr. Ellen Jones and three other physicians. The contract between Community and VEPPA states that Dr. Jones and the other physician employees of VEPPA are not employees or agents of the hospital and further states that the hospital will not be liable for any negligence by VEPPA or its physician employees. In that regard, the hospital has placed the following sign on the wall in the emergency department: Community General Hospital wants you to know that the physicians working in the emergency department are employees of VEPPA and are not employees or agents of the hospital. Have a nice day ! On her arrival at Community’s emergency department, Ms. Grant told the nurse on duty that she had a splitting headache, and she was briefly examined by nurse Rebecca Smith. Then she was examined by the doctor on duty, Dr. Jones. Ms. Grant had no prior relationship with Dr. Jones. According to the hospital’s written protocols for the emergency department, if an adult patient complains of a splitting headache and that patient does not appear to be intoxicated, the patient should be given a computed tomography (CT) scan of the head as soon as possible. In addition to being Community’s protocol, that method of diagnosis is the ordinary practice at all of the hospitals in the area. However, some of the third-party payers have begun to refuse to pay for CT scans under these circumstances. Nurse Smith asked Ms. Grant about her health insurance. Ms. Grant said that she was covered by the Good-Health HMO and gave Nurse Smith an HMO membership card that contained her policy number and a phone number for the HMO. Nurse Smith called the office of the HMO to verify Ms. Grant’s coverage and to request authorization for the CT scan. However, the clerk on duty at the HMO informed Nurse Smith that Good-Health HMO no longer pays for CT scans of the head under these circumstances. Instead, the HMO clerk said that the hospital should instruct Ms. Grant to call her primary care physician at the HMO when the office opened at 9 a.m. the next day. Nurse Smith informed Dr. Jones of the HMO’s decision, and Dr. Jones discharged Ms. Grant at 10:30 p.m. with instructions to call her primary care physician at the HMO the next morning. Dr. Jones did not tell Ms. Grant that the usual diagnostic test for her condition was a CT scan, which Ms. Grant could have paid for with the credit card that she carried in her wallet. Ms. Grant’s friend took her home, where she died of an aneurism at approximately 11:45 p.m. that night. AT the request of the next of kin, an autopsy was performed on the body of Ms. Grant. According to the autopsy report, Ms. Grant died of a rare type of aneurism that does not show up on a CT scan.

Questions: What claims could be asserted against Community by Ms. Grant’s estate? In discussing each potential Claim against Community, be sure to discuss the elements of each claim, and the likelihood of success on each claim. *Note: In responding to these above questions, do not discuss any potential claims against individual healthcare professionals, VEPPA, the Good-Heath HMO, or the law firm’s health plan. (Only EMTALA issue)

Answer 1

According to EMTALA emergency departments can not refuse to treat people based on their insurance status or ability to pay. It was clear in this situation, Ms Jones could have paid for a CT scan, as the nurse did not even bother to ask for the permission, it was a direct negligence of duty.

• CT scan would have taken place as the claim is valid.
• Without any diagnosis, she was dischaged from emergency care.
• Permission was not even sought for paying for CT scan, seeing it as an emergency, but the claim is valid.
• CT scan would not have shown the problem, but then the next course of action could have been possible, which was not initiated.