EMTALA and Billing: What You Can Ask Patients and When
An ED may ask whether a patient is insured and what the insurance is, as long as the question does not delay screening or treatment. It may not delay the exam to ask about payment, and it may not seek insurer authorization before the exam and the start of stabilizing treatment.
Written by Salman Saeed, CEO and Co-Founder · Reviewed by a Certified Medical Coder · 
In short: registration can ask whether the patient is insured, but never ahead of or in place of the exam. Hold authorization calls until stabilizing treatment has started, and write the copayment policy with compliance.
Can an ED Ask About Insurance or Payment Before the Screening Exam?
Registration may ask whether the patient is insured and which insurance it is, as long as the question does not delay screening or treatment. That is 42 CFR 489.24(d)(4)(iv). What a hospital may not do is delay the exam to ask about payment, or seek insurer authorization before the exam and the start of stabilizing treatment.
The EMTALA and billing rule page covers the law. This post is the working version for registration and billing leads: an action-by-action table, a sequence for the door, wording to avoid and what the chart should hold.
What Can Registration Do, and When?
| Action | Allowed? | Basis in 42 CFR 489.24 |
|---|---|---|
| Ask whether the patient is insured and what the insurance is | Yes, if it does not delay screening or treatment | (d)(4)(iv) |
| Hold the screening exam until insurance details are collected | No | (d)(4)(i): no delay to inquire about method of payment or insurance status |
| Ask the insurer for authorization, or tell the patient to get it | Not until after the screening exam and the start of any needed stabilizing treatment | (d)(4)(ii) |
| Call the patient's own physician for history relevant to care | Yes, at any time, if it does not inappropriately delay required services | (d)(4)(iii) |
| Run registration in a way that makes patients want to leave | No: reasonable registration may not unduly discourage patients from remaining for further evaluation | (d)(4)(iv) |
| Ask for a copayment or deposit | The regulation does not mention copayments. The test is delay and discouragement, so write the policy with compliance or counsel | (d)(4)(i) and (iv) |
| Bill the patient or insurer after the visit | Nothing in 489.24 bars billing. Normal payer rules apply | Whole section read |
The copayment row is where hospitals differ. The regulation is silent on the word, so the safe reading is the one the text supports: if the request holds up care or pushes the patient to leave, it fails the test.
What Should the Registration Sequence Look Like at the Door?
What Does a Compliant Timeline Look Like?
A patient arrives at 7:50 pm with severe back pain and difficulty urinating.
The pattern to avoid is the reverse: an insurance call at 7:55, before the exam, or a clerk telling the patient the visit will not start until a deposit is paid.
What Should Staff Avoid Saying?
- Anything that ties the exam to payment, such as 'we cannot see you until the insurance is verified.'
- Cost warnings that could push a patient to leave. Registration may not unduly discourage patients from remaining for evaluation.
- Statements that the patient must get insurer approval before being treated.
- Sending an unstabilized patient elsewhere for payment reasons. A transfer needs the written request or physician certification that 489.24(e) describes.
Staff can say plainly that a clinician will see the patient now and that a registration colleague will come to the bedside. Have compliance approve the exact wording and train to it.
What Can You Tell Patients About the Bill?
For an insured patient with an emergency medical condition at a hospital ED or independent freestanding emergency department, a nonparticipating facility must not bill more than the in-network cost-sharing requirement for emergency services. 45 CFR 149.410(a)(1) says so, and (a)(2) says the same for a nonparticipating provider.
The No Surprises Act definition of emergency services reaches the screening exam and the treatment needed to stabilize the patient, and in some cases services after stabilization. The No Surprises Act hub and the guide for ER groups explain the rest, and the notice and consent page covers the narrow conditions in 149.410(b).
What Should the Chart Hold so the Claim Stands?
- The time of arrival, the time the screening exam started and who performed it.
- The time stabilizing treatment started, as the earliest point for an authorization call.
- Any refused exam, treatment or transfer, with the written informed refusal.
- For a transfer of an unstabilized patient: the written request or physician certification, plus the records sent.
On the claim, the hospital reports the visit on the UB-04 with revenue code 0450. How it chooses the visit level is in how to set ED facility E/M levels.
How Does Nucleus Align Fit In?
EMTALA compliance is the hospital's duty and the policy belongs to compliance or counsel. We handle the billing that follows: our hospital and facility billing team does UB-04 claim preparation, revenue-code validation, submission, payment reconciliation and denial management for emergency care, with automated eligibility checks. To review how your ED claims flow, book a call.
- 42 CFR 489.24 Special responsibilities of Medicare hospitals in emergency cases · eCFR
- 45 CFR 149.410 Balance billing in cases of emergency services · eCFR
- 45 CFR 149.110 Preventing surprise medical bills for emergency services · eCFR
We check every rule, code and deadline against the official source. See our editorial policy.
Common Questions
Straight answers from the team that does the work.
Ask a billing lead directly. A 20-minute call, Monday to Friday, 9am to 5pm Eastern.
01Can an ED ask about insurance or payment before screening?
It may ask whether the patient is insured and what the insurance is, if the question does not delay screening or treatment. Under 42 CFR 489.24(d)(4)(i), a hospital may not delay the exam to inquire about payment or insurance status, and registration may not unduly discourage patients from staying.
02When can a hospital request insurer authorization in the ED?
Only after it has provided the screening exam and initiated any further examination and treatment needed to stabilize the emergency medical condition. Under 489.24(d)(4)(ii), it may not seek, or direct the patient to seek, authorization from the insurer before that point.
03Can a hospital collect a copayment from an ED patient?
The regulation does not mention copayments. Its test is whether a request for money delays the exam or treatment, or unduly discourages the patient from remaining for evaluation. Set the policy with compliance or counsel, and keep any request out of the way of care.
04Does EMTALA stop a hospital from billing the patient or insurer?
No. Section 489.24 controls timing and conduct, not billing after the visit. For insured patients, the No Surprises Act limits what a nonparticipating facility or provider can bill for emergency services to the in-network cost-sharing amount under 45 CFR 149.410(a).
Talk to a Billing Lead.
A 20-minute call about your payers, volume and setup. Monday to Friday, 9am to 5pm Eastern.