While emergency physicians are available 24 hours a day, 7 days a week, other medical specialists are "on-call," which means they are called in as needed. On-call physicians, such as neurosurgeons, cardiologists, and orthopedists, provide services to hospital emergency departments to medically screen and stabilize emergency conditions.

Every day in the United States, nearly 300,000 patients request care from emergency departments. Many have serious illnesses or injuries that require consultation with medical specialists, hospitalization, or surgical intervention.

Yes. The Centers for Medicare and Medicaid Services clearly places the responsibility on hospitals to have an on-call list that meets the needs of patients.

The Emergency Medical Treatment and Labor Act (EMTALA) also places responsibility on hospitals to ensure the availability of emergency care for all who need it, regardless of their insurance status, citizenship, or ability to pay. As part of this obligation, hospitals offering emergency care must ensure that specialists are accessible to treat and stabilize emergency medical conditions.

• Medical staff by-laws, policies, rules, and procedures therefore must be consistent with EMTALA requirements and define the responsibilities of on-call physicians to respond, examine, and treat patients. Although physicians are not required to be on-call at all times, hospitals must identify contingency plans for when particular specialties are not available or on-call physicians can't respond.

Yes. This is especially true in rural areas, where populations are small and cannot support the practices of specialty physicians who provide on-call coverage.

Lack of funding for specialty services has seriously damaged the infrastructure of specialty backup for the nation's emergency departments. Since many patients seeking emergency care are uninsured or underinsured, on-call physicians often are not compensated for the care they provide to these patients.

On-call physicians must respond to emergency calls within a timely manner or risk stiff federal financial penalties.

• On-call physicians, who may be on-call at another hospital, must not request a patient's transfer to another hospital for the physician's convenience. When transferring a patient to another facility, the transferring physician must discuss the case with the receiving hospital's authorized representative and obtain agreement to accept the patient. (All hospitals with specialized capabilities, including physician specialists, have a responsibility to accept a transfer when it is necessary to stabilize an emergency medical condition).

• On-call physicians who, as part of their routine responsibilities, are charged with accepting patients transferred from other facilities, may not refuse any unstable transfers as long as their hospital has the capability and capacity to provide treatment.

Medicare-participating hospitals and physicians found to be in violation of EMTALA could be sanctioned as follows:

• Termination of the hospital and/or physician from participation in the Medicare and Medicaid programs.

• Civil monetary penalties against the hospital with 100 or more beds of $50,000 per violation. The fine per violation for hospitals with less than 100 beds cannot exceed $25,000.

• Civil monetary penalties for physicians up to $50,000 per violation.

• On-call physicians responsible for examination, treatment, or transfer of a patient are subject to potential civil fines of up to $50,000 per violation for failing to come to the hospital, as well as exclusion from the Medicare program.