Physician Refusal to Respond: Penalties and Hospital Liability (42 U.S.C. § 1395dd(d)(1))

Physician refusal to respond to emergency calls is one of the most serious EMTALA violations. Under 42 USC 1395dd(d)(1), both hospitals and individual physicians may face civil monetary penalties for failing to provide necessary services to stabilize a patient with an emergency medical condition. Small practices often underestimate their exposure, especially when their clinicians participate in hospital call rotations, contract with ED-adjacent practices, or provide specialty services under hospital by laws. This article explains the legal requirements, the penalties for nonresponse, and how small practices can prevent catastrophic EMTALA violations with simple, low-cost controls.

Emergency on-call obligations form the backbone of EMTALA’s guarantee that any patient arriving at a hospital with an emergency medical condition receives timely stabilizing care. But when a physician refuses to respond, citing inconvenience, scheduling conflicts, or personal priorities, the consequences reach far beyond the ED. Under 42 USC 1395dd(d)(1), individual physicians and the hospitals they support can be penalized when failure to respond contributes to delayed stabilization or transfer.

Small practices face unique vulnerabilities. Many clinicians split time between office visits, urgent care, and call panels at partnering hospitals. Miscommunication or lack of structured on-call systems can inadvertently create EMTALA violations. This article provides a practical, compliant framework to help small practices meet federal expectations without adding unnecessary administrative load.

Understanding Legal Framework & Scope Under 42 USC 1395dd d 1

1. Statutory Basis for Penalties

42 USC 1395dd(d)(1) imposes civil monetary penalties when:

• A hospital negligently violates EMTALA requirements, or

• A physician responsible for examination, treatment, or call coverage negligently refuses to respond or fails to provide necessary stabilizing care.

Penalties apply when:

• A patient presents with an emergency medical condition,

• The physician is on-call or responsible for emergency response, and

• The physician’s refusal contributes to delayed stabilization or transfer.

2. Liability Scope

Penalties may be assessed against:

• Individual physicians

• Physician groups contracted to provide specialty services

• Hospitals relying on the physician’s coverage

• Small practices operating under call agreements

3. On-Call Coverage Requirements

A physician’s obligations begin once listed on the ED’s on-call roster. EMTALA does not allow:

• Selective refusals

• Delayed responses

• “Phone-only” management when bedside evaluation is required

4. Federal vs State Interactions

State laws govern licensure, discipline, and medical board actions, but EMTALA defines federal liability and penalties. EMTALA obligations override conflicting state protections when emergency medical conditions are involved.

5. Why This Matters for Small Practices

A single refusal-to-respond incident can result in:

• CMS investigations

• OIG civil monetary penalties

• Termination of hospital privileges

• Contract dissolution

• Severe business disruption

Understanding this framework prevents operational and financial fallout.

CMS identifies EMTALA violations through:

• Patient complaints

• Hospital reports

• Transfer complications

• Delayed stabilization incidents

OIG has exclusive authority to impose civil monetary penalties under 42 USC 1395dd(d)(1).

• On-call physician does not respond within required timeframe.

• On-call physician declines to come in, stating the patient “isn’t appropriate” without an exam.

• On-call specialist instructs ED staff to transfer without stabilizing intervention.

• Physician refuses due to insurance status or administrative disagreements.

• Documentation shows multiple unanswered calls or lack of escalation.

Small practices are often cited when staff fail to maintain accurate on-call logs or when communication channels break down.

These controls support small practices with limited budgets, ensuring compliance with 42 USC 1395dd(d)(1) and protecting against physician nonresponse risks.

1. Centralized On-Call Coverage Log

Accurate logs are essential to prove compliance.

• Implementation: Maintain a single master schedule shared with hospital partners.

• Evidence: Timestamped entries showing who was on call, contact attempts, and responses.

• Low-cost option: Free shared spreadsheet accessible from mobile devices.

2. Rapid-Response Escalation Pathway

If an on-call physician does not respond immediately, escalation must be documented.

• Implementation: Establish a 5-minute and 10-minute escalation ladder (e.g., physician → group lead → ED clinical director).

• Evidence: Entry in communication log citing 42 USC 1395dd(d)(1) risk.

• Low-cost option: Laminated escalation card at staff stations.

3. Real-Time Contact Verification Protocol

Ensure contact numbers are always up-to-date.

• Implementation: Monthly verification of phone numbers and backup lines.

• Evidence: Updated contact sheet stored in compliance folders.

• Low-cost option: Monthly automated text asking physicians to confirm numbers.

4. Minimum Response Standards for On-Call Physicians

Physicians must respond within a reasonable timeframe to avoid EMTALA liability.

• Implementation: Define required bedside response expectations (e.g., 20–30 minutes, depending on specialty).

• Evidence: Timestamp comparing hospital call to physician arrival.

• Low-cost option: Policy posted in the on-call handbook.

5. Documentation of Physician Advice During Calls

If clinical advice is provided prior to arrival, it must be recorded.

• Implementation: Require staff to summarize instructions in the patient’s note and the call log.

• Evidence: Documentation with phrase “Guidance received; awaiting arrival.”

• Low-cost option: Simple template inserted into EHR.

6. Cross-Coverage Assignment Process

When physicians swap coverage, the hospital must be notified.

• Implementation: Require formal cross-coverage notice with start/end time.

• Evidence: Email or form stored in shared drive.

• Low-cost option: Free form builder.

7. Post-Event Review for Delayed Responses

Every nonresponse or delayed response must be reviewed.

• Implementation: Conduct a review within 48 hours.

• Evidence: Summary report showing cause, impact, and corrective action.

• Low-cost option: Short standardized incident review form.

These controls prevent nonresponse events and ensure compliance with the statutory penalty structure.

Case Study

A cardiologist participating in a small specialty group was on-call for a partner hospital’s ED. A 63-year-old man arrived with crushing chest pain. ED physicians paged the cardiologist three times over 12 minutes. The cardiologist refused to come, stating he was “too far” and advising the ED to transfer the patient.

The hospital transferred the patient without specialist evaluation. The receiving hospital filed a complaint noting that the patient arrived unstable and required emergent catheterization.

Consequences

CMS determined that:

• The cardiologist violated EMTALA by refusing to respond while on-call.

• The hospital failed to enforce its call requirements.

• The transfer lacked stabilizing evaluation.

OIG imposed penalties under 42 USC 1395dd(d)(1):

• The cardiologist was fined.

• The hospital was fined separately.

• The small practice’s contract with the hospital was suspended pending corrective actions.

How the Playbook Would Have Prevented This

If the practice used the centralized on-call log, rapid escalation steps, and verified contact numbers, the event would have triggered early escalation and ensured timely response. Documentation would have demonstrated compliance, even if response delays occurred.

Common Audit Pitfalls to Avoid Under 42 USC 1395dd d 1

Physician nonresponse often stems from preventable operational gaps.

• Failure to clearly define response time requirements, causing inconsistent expectations among physicians.

• Lack of escalation procedures, leaving staff uncertain how to respond when a physician is unreachable.

• Assuming phone advice is sufficient, even when bedside evaluation is required for stabilization.

• Outdated contact information, often cited in CMS investigations.

• No documentation of attempted calls, preventing proof of compliance.

• Ignoring repeated nonresponse behavior, signaling systemic failure that increases liability.

Fixing these pitfalls significantly reduces EMTALA exposure and strengthens organizational readiness under 42 USC 1395dd(d)(1).

A strong culture around on-call compliance begins with clear expectations, transparent accountability, and continuous communication. Leadership should assign a compliance owner to manage call schedules, contact verification, and incident review. Training should emphasize that on-call responsibilities are legal obligations, not voluntary conveniences. Metrics, such as average response times, number of late responses, and frequency of escalation, should be monitored monthly. A governance model built on clarity and accountability prevents nonresponse events that can lead to severe penalties.

Physician refusal to respond carries severe consequences under 42 USC 1395dd(d)(1). Even small practices must structure on-call processes to prevent delays that jeopardize stabilization. With simple communication tools, escalation rules, and consistent documentation, small clinics can meet federal expectations and protect both patients and clinicians.

Next Steps

1. Deploy a shared on-call communication log.

2. Establish strict response time standards and communicate them to all clinicians.

3. Implement escalation protocols for nonresponse.

4. Verify and update physician contact pathways monthly.

5. Conduct post-event reviews within 48 hours of any late or failed response.

Recommended compliance tool

A shared “Medicare Plan Interaction” log and policy folder on your existing network or EHR, used to store scripts, training records, and any sponsor correspondence about beneficiary communications.

Advice: 

Before the next open enrollment, walk through your clinic as an auditor would and remove or rewrite anything that could be interpreted as recommending one Part D plan over another.

• Emergency Medical Treatment and Labor Act (42 USC 1395dd)
  

• CMS State Operations Manual, Appendix V – EMTALA Guidelines
  

• Federal Register EMTALA Rulemaking
  

• HHS Office of Inspector General – Civil Monetary Penalties Law Guidance