When Does EMTALA Apply? The Semantics of Emergency Care


A recent court case challenges whether “urgent” care clinics will have to meet the same EMTALA standards as a dedicated emergency department.

This month’s case was highlighted in the Journal of Urgent Care Medicine in an article titled, “Federal Judge Says EMTALA Covers Hospital-Owned Urgent Care Center.” The article describes a Rhode Island US District Court opinion holding that EMTALA requirements may apply to urgent care clinics. The case involved a patient with “burning” chest pain radiating to her right arm. She sent texts to her co-workers that she was leaving to “get checked out for a heart attack.” She was diagnosed with GERD, given a GI cocktail, and discharged. The following day, she died from atherosclerotic heart disease. Among multiple allegations in the resulting lawsuit, the patient’s estate alleged an EMTALA violation since the urgent care center allegedly failed to provide a screening exam to detect the patient’s emergency medical condition. The clinic argued that it was not a “dedicated emergency department” under EMTALA, so EMTALA’s requirements didn’t apply. The court ruled that EMTALA may apply to urgent care clinics. CMS rules regarding interpretation of EMTALA and “dedicated emergency departments” state that “most urgent care centers will meet the revised definition of dedicated emergency department for purposes of EMTALA.” The court noted that the clinic “deliberately used the word ‘urgent’ in naming the Urgent/Walk-in Care; it could have simply called it a ‘Walk-in’ clinic.” From a practical standpoint, the court described how “it would be very difficult for any individual in need of emergency care to distinguish between a hospital department that provides care for an ‘urgent’ need and one that provides care for an ‘emergency medical condition’ need.” Friedrich v. South County Hospital Healthcare, et al., US District Court Rhode Island CA No 14-353 (2017).


1. CMS is expanding the definition of “emergency department” under EMTALA
Hospital-based urgent care clinics may have EMTALA duty even though those clinics are not equipped to stabilize true emergency medical conditions. If an urgent care clinic cannot provide diagnostic testing and treatment similar to that provided in an emergency department, there may be a duty to transfer patients with potential emergency medical conditions to a formal emergency department. Determinations of potential EMTALA violations are made retrospectively. As with this case—where the patient’s pain did not seem to be cardiac-related—retrospective bias will likely affect the determination if a patient suffers a bad outcome (i.e. “Since the patient died from cardiac disease, the atypical chest pain must have represented an emergency medical condition that wasn’t stabilized.”). So far, this decision only applies to Rhode Island, but the court’s reasoning may be used by other courts in the future.


2. An allegation of an EMTALA violation will likely bring a federal investigation
Federal investigations of potential EMTALA violations involve significant additional expense to the hospitals and may result in disciplinary measures and fines imposed by CMS—none of which will make hospital administrators very happy. Allegations of EMTALA violations don’t even require a patient injury

3. Know what is in the contract you signed
Many large contract management groups and locum tenens companies are now trying to sneak indemnification clauses into their employment and independent contractor agreements. If you agree to an indemnification clause and are later the physician who happens to send home the next heart attack with atypical chest pain from the urgent care clinic, you have to pay for any fines and damages that the hospital incurs. You could potentially lose your life savings, your house, and any other asset you own. Remember that malpractice insurance doesn’t cover contractual indemnity—all indemnification payments come out of your pocket.



SENIOR EDITOR DR. SULLIVAN, an emergency physician and clinical assistant professor at Midwestern University in Illinois, is EPM’s resident legal expert. As a health law attorney, Dr. Sullivan represents medical providers and has published many articles on legal issues in medicine. He is a past president of the Illinois College of Emergency Physicians and a past chair and current member of the American College of Emergency Physicians’ Medical Legal Committee. He can be reached at his legal web site http://sullivanlegal.us.


  1. We need to figure this out and other ER vs. urgent care issues and then clearly communicate it to patients and the general public. Urgent care vs ER vs freestanding ER and now, possibly, urgent care with or without EMTALA requirements. We need a clearly defined standard of care that we can provide each patient without superfluously blowing up medical bills by mandating too many unused health resources.

    • Terri Jordan, PA-C on

      I agree with Angela above. Clearly Urgent Cares an Acute Care Clinics are not set up with equipment or skill sets that ERs have. I think that any patient having burning chest pain regardless of what clinic they present to, including their PCM, should be vigilant enough to know that typical or atypical symptoms of cardiac issues should always be evaluated and that ONLY serial enzymes can rule out cardiac involvement. Any clinic should understand what requires higher level evaluation and follow through with it. Any urgent care is not obligated to see or treat any patient but they have a legal obligation to evaluate a patient with a potentially life threatening issue regardless of the ability to pay. Having UC/ACs fall under all of EMTALA is a slippery slope. Regardless of what the law is, health care providers need to know how, what, where, and when EMTALA applies. This article has not made this very clear except for this specific instance.

  2. Deborah Coughlin on

    Once a pt is admitted to the floor from ER, then pt receives an injury of any kind, Does the pt then need to come back down to the ER to be treated.
    This involves a shoulder dislocation.

  3. Mary Beth Deering, MD on

    My question is in regards to clinics which offer to see broken bones.., but do not have xray capabilities or splints to temporarily immobilize a suspected fracture. The individual is sent to an outside facility (not an ER or urgent care, just diagnostic facility) then sent home . No temporary stabilization is provided. I am seeing this with children . We receive a referral days later and the child is walking around with a significant broken bone. It has resulted in escalation of care to the OR because the fracture became malreduced. Doesn’t really seem to fall under the EMTALA rules. Any advice?

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