                                     PUBLISHED

                      UNITED STATES COURT OF APPEALS
                          FOR THE FOURTH CIRCUIT


                                     No. 18-2139


TERENCE WILLIAMS,

            Plaintiff – Appellant,

v.

DIMENSIONS HEALTH CORPORATION, trading as Prince George’s Hospital
Center,

            Defendant – Appellee.


Appeal from the United States District Court for the District of Maryland, at Greenbelt.
Paul W. Grimm, District Judge. (8:16-cv-04123-PWG)


Argued: January 28, 2020                                      Decided: March 13, 2020


Before DIAZ, THACKER, and QUATTLEBAUM, Circuit Judges.


Affirmed by published opinion. Judge Quattlebaum wrote the opinion in which Judge Diaz
and Judge Thacker joined.


ARGUED: Jon Wyndal Gordon, LAW OFFICE OF J. WYNDAL GORDON, PA,
Baltimore, Maryland, for Appellant. Christian W. Kintigh, DOWNS WARD BENDER
HAUPTMANN & HERZOG, P.A., Hunt Valley, Maryland, for Appellee. ON BRIEF:
Mary Alane Downs, DOWNS WARD BENDER HAUPTMANN & HERZOG P.A., Hunt
Valley, Maryland, for Appellee.
QUATTLEBAUM, Circuit Judge:

       Shortly after midnight on May 3, 2014, Terence Williams was seriously injured

when his vehicle rolled over in a single-vehicle accident. Williams’ most serious injuries

were to his lower body. He was subsequently transported to Prince George’s Hospital

Center (the “Hospital”) in Prince George County, Maryland. He arrived at the Hospital at

1:33 A.M., and Hospital staff began screening procedures. Within twenty minutes, he was

intubated to protect his airway, and a trauma surgeon performed a right antecubital

cutdown to insert a catheter to infuse large volumes of fluid and blood quickly. After the

insertion of the catheter, Williams was repeatedly given blood for the next several hours.

Between 2:21 A.M. and 2:57 A.M., various CT scans were performed on his head, chest

and spine. At 3:23 A.M., Williams was removed off the back board provided by paramedics

in the field. At the same time, he was given additional units of blood and plasma. Twenty

minutes later, x-rays were performed on his chest, abdomen, pelvis, forearm, femur, spine,

tibia and fibula. After the x-rays, Williams was transported to the operating room and began

receiving anesthesia. At 5:13 A.M., Williams’ first surgery began and lasted more than six

hours. Although the formal documentation is ambiguous, at some point on May 3, Williams

concedes he was admitted to the Hospital.

       For the next eleven days, Hospital staff performed a variety of surgeries and medical

treatments on Williams. On May 13, 2014, he was transferred to the University of

Maryland Medical Center. Despite the treatment he received at the Hospital and at the

University of Maryland, the injuries to Williams’ lower body required amputating both of

Williams’ legs.

                                             2
       Williams sued the Hospital in state court, alleging it violated the Emergency

Medical Treatment and Active Labor Act (“EMTALA”) by failing to properly screen him

and stabilize his condition. The Hospital removed the case to federal court and then moved

to dismiss Williams’ complaint.

       The district court granted in part and denied in part the Hospital’s motion. It treated

the motion as a motion for summary judgment because Williams attached exhibits to his

opposition that were not attached or referenced in his complaint. It then held that the

Hospital was entitled to judgment as a matter of law on Williams’ failure to screen claim:

“[The hospital] followed its own standard screening procedures when it provided an initial

screening for Williams. Whatever shortcomings Williams may perceive in the physician

assistant’s screening or the physicians’ involvement, those are matters for a medical

malpractice action, and outside the scope of an EMTALA action.” J.A. 153. The district

court denied the Hospital’s motion with respect to Williams’ failure to stabilize claim,

holding “until a patient is transferred, discharged, or admitted, ‘the Hospital must provide

that treatment necessary to prevent the material deterioration of each patient’s emergency

medical condition.’” J.A. 155 (citing In the Matter of Baby K, 16 F.3d 590, 596 (4th Cir.

1994)). As the district court explained, “[a]t some point, . . . Williams was admitted to the

hospital. Thus, [Williams] has stated a claim for failure to stabilize, given that it is plausible

that the Hospital failed to stabilize his emergency medical condition before it admitted him,

such that his condition materially deteriorated.” J.A. 157 (emphasis added).

       The Hospital later moved for summary judgment on the remaining stabilization

claim. The district court granted the Hospital’s motion noting that “contrary to [its]

                                                3
understanding when [it] considered the parties’ argument for the Hospital’s first dispositive

motion,” the timing of a patient’s admission to the hospital is not essential because the

good faith admission of an individual as an inpatient is a complete defense to an EMTALA

failure to stabilize claim. J.A. 237. Without determining the exact time, the district court

found that Williams was in fact admitted and held that Williams failed to present evidence

that created a genuine issue of material fact about the Hospital’s good faith in admitting

Williams. Thus, the district court granted the Hospital’s motion for summary judgment.

       Williams filed a timely notice of appeal on June 29, 2018, and we have jurisdiction

under 28 U.S.C. § 1291. On appeal, Williams raises a single, narrow issue, arguing that his

admission to the Hospital lacked good faith. 1 For the reasons set forth below, we affirm the

district court.



                                             I.

       Before analyzing the good faith admission issue presented here, we briefly describe

EMTALA and its requirements. Congress enacted EMTALA in 1986 to prevent patient

dumping, a practice by which hospitals would either refuse to provide emergency medical

treatment to patients unable to pay for treatment or transfer those patients before their

emergency medical conditions were stabilized. Vickers v. Nash Gen. Hosp., Inc., 78 F.3d




       1
        We review the district court’s grant of summary judgment de novo, viewing the
evidence in the light most favorable to Williams. Iraq Middle Mkt. Dev. Found. v.
Harmoosh, 947 F.3d 234, 237 (4th Cir. 2020).

                                             4
139, 142 (4th Cir. 1996); Bryan v. Rectors and Visitors of Univ. of Va., 95 F.3d 349, 351

(4th Cir. 1996).

       In keeping with this purpose, EMTALA imposes two main obligations on hospitals

with emergency rooms. First, EMTALA requires a hospital to screen an individual to

determine whether he has an emergency medical condition. 42 U.S.C. § 1395dd(a)

provides:

       In the case of a hospital that has a hospital emergency department, if any
       individual (whether or not eligible for benefits under this subchapter) comes
       to the emergency department and a request is made on the individual’s behalf
       for examination or treatment for a medical condition, the hospital must
       provide for an appropriate medical screening examination within the
       capability of the hospital’s emergency department, including ancillary
       services routinely available to the emergency department, to determine
       whether or not an emergency medical condition (within the meaning of
       subsection (e)(1) of this section) exists.

42 U.S.C. § 1395dd(a). EMTALA defines emergency medical condition as:

       (A) a medical condition manifesting itself by acute symptoms of sufficient
       severity (including severe pain) such that the absence of immediate medical
       attention could reasonably be expected to result in--
       (i) placing the health of the individual (or, with respect to a pregnant
       woman, the health of the woman or her unborn child) in serious jeopardy,
       (ii) serious impairment to bodily functions, or
       (iii) serious dysfunction of any bodily organ or part;

42 U.S.C. § 1395dd(e)(1)(A).

       Second, EMTALA requires a hospital to stabilize an individual’s emergency

medical condition in certain limited circumstances. 42 U.S.C. § 1395dd(b)(1) provides:

       If any individual (whether or not eligible for benefits under this subchapter)
       comes to a hospital and the hospital determines that the individual has an
       emergency medical condition, the hospital must provide either--



                                             5
       (A) within the staff and facilities available at the hospital, for such further
       medical examination and such treatment as may be required to stabilize the
       medical condition, or
       (B) for transfer of the individual to another medical facility in accordance
       with subsection (c) of this section.

42 U.S.C. § 1395dd(b)(1).

       Critically, EMTALA defines “to stabilize” as “to provide such medical treatment of

the [emergency medical condition] as may be necessary to assure, within reasonable

medical probability, that no material deterioration of the condition is likely to result from

or occur during the transfer of the individual from a facility . . . .” 42 U.S.C.

§ 1395dd(e)(3) (emphasis added). EMTALA defines transfer as “the movement (including

the discharge) of an individual outside a hospital’s facilities at the direction of any person

employed by (or affiliated or associated, directly or indirectly, with) the hospital, but does

not include such a movement of an individual who (A) has been declared dead, or (B)

leaves the facility without the permission of any such person.” 42 U.S.C. § 1395dd(e)(4).

Thus, under the statute itself, “the stabilization requirement only sets forth standards for

transferring a patient in either a stabilized or unstabilized condition. By its own terms, the

statute does not set forth guidelines for the care and treatment of patients who are not

transferred.” Harry v. Marchant, 291 F.3d 767, 771 (11th Cir. 2002) (emphasis in original).

       Consistent with this definition, this Court in Bryan v. Rectors and Visitors of

University of Virginia, 95 F.3d 349 (4th Cir. 1996), held that EMTALA’s stabilization

requirement is “defined entirely in connection with a possible transfer and without any

reference to the patient’s long-term care within the system.” Id. at 352. Elaborating on the

scope of the requirement, this Court held:

                                              6
       It seems manifest to us that the stabilization requirement was intended to
       regulate the hospital’s care of the patient only in the immediate aftermath of
       the act of admitting her for emergency treatment and while it considered
       whether it would undertake longer-term full treatment or instead transfer the
       patient to a hospital that could and would undertake that treatment. It cannot
       plausibly be interpreted to regulate medical and ethical decisions outside
       that narrow context.

Id. (emphasis added). 2

       Subsequent regulations from the Centers for Medicare & Medicaid Services (the

“CMS”) confirm the limited scope of the stabilization requirement. 3 A 2003 final rule from

the CMS adopted the approach of Bryan and the approach of other circuits, including

Harry, providing “should a hospital determine that it would be better to admit the

individual as an inpatient, such a decision would not result in a transfer or a discharge, and,

consequently, the hospital would not have an obligation to stabilize under EMTALA.”

CMS Final Rule, 68 F.R. 53222-01, 2003 WL 22074670, at *53244 (F.R. Sept. 9, 2003).

This codified rule provides:

       If a hospital has screened an individual under paragraph (a) of this section
       and found the individual to have an emergency medical condition, and admits
       that individual as an inpatient in good faith in order to stabilize the
       emergency medical condition, the hospital has satisfied its special
       responsibilities under this section with respect to that individual.

       2
         Although Williams relies on In the Matter of Baby K, 16 F.3d 590 (4th Cir. 1994)
to argue for a broader stabilization requirement, he misconstrues its holding. As explained
in Bryan, “[t]he holding in Baby K thus turned entirely on the substantive nature of the
stabilizing treatment that EMTALA required for a particular emergency medical condition.
The case did not present the issue of the temporal duration of that obligation, and certainly
did not hold that it was of indefinite duration.” 95 F.3d at. 352.
       3
        The CMS, as part of the Department of Health and Human Services, has the
congressional authority to promulgate rules and regulations interpreting and implementing
EMTALA. Torretti v. Main Line Hospitals, Inc., 580 F.3d 168, 174 (3d Cir. 2009).

                                              7
42 C.F.R. § 489.24(d)(2)(i).

       But, importantly, the regulations refer to an admission that is “in good faith.” Thus,

while the CMS clarified that admission is a defense to a stabilization claim, it, at the same

time, imposed a good faith requirement to that admission. Explaining this requirement

further, the CMS cautioned that a hospital cannot admit an individual solely to evade

liability under EMTALA:

       However, a hospital cannot escape liability under EMTALA by ostensibly
       “admitting” a patient, with no intention of treating the patient, and then
       inappropriately transferring or discharging the patient without having met the
       stabilization requirement. If it is discovered upon investigation of a specific
       situation that a hospital did not admit an individual in good faith with the
       intention of providing treatment (that is, the hospital used the inpatient
       admission as a means to avoid EMTALA requirements), then liability under
       EMTALA may attach.

68 F.R. 53222-01, 2003 WL 22074670, at *53245. This regulation confirmed that a

hospital’s admission of a patient for treatments effectively acts as a defense to an EMTALA

claim. But the CMS also articulated what might be described as a defense to the defense—

the requirement that the admission be in good faith. Under that requirement, Williams’

claim might survive summary judgment if he can show that the Hospital’s admission was

not in good faith. We now turn to that question.



                                             II.

       On appeal, Williams does not argue that the Hospital failed to admit him on May 3,

2014. Instead, he challenges the district court’s conclusion that his admission was in good




                                             8
faith. 4 In arguing his admission was not, Williams asserts that his admission was based on

non-medical reasons. More specifically, he argues the Hospital failed to provide the full

number of specialized on-call doctors required by law and by its internal procedures; the

Hospital’s trauma surgeon, who was available on call, refused to perform surgery; and the

Hospital attempted to hoard Williams as a patient to collect his premium insurance benefits.

Appellant Br. at 14.

       Before addressing the merits of Williams’ argument, we must first determine

whether the good faith admission requirement applies in this Circuit. While both parties

assume that it does, we have an independent obligation to assess the viability of the

requirement in light of our precedent and applicable regulations. Our Court has yet to

address the requirement of good faith admission under EMTALA, and it is not expressly

set forth in the statute. But, based on several circuit court decisions, including our Bryan

decision, the CMS’s 2003 regulation explained that the defense to an EMTALA claim

based on the admission of the patient requires that the admission be in good faith. This

requirement appears to have the force and effect of law in an area where Congress has not




       4
         Although Williams maintains that he is solely appealing the district court’s
determination that his admission was in good faith, to the extent that he argues that the
hospital breached its duty to stabilize, his argument must fail because the hospital admitted
him as a patient. While the record is not entirely clear about the precise time of his
admission, Williams concedes he was admitted to the hospital on May 3, receiving
extensive treatments and surgeries throughout that day and for another ten days thereafter.
As explained above, a hospital has no obligation under EMTALA to stabilize a patient’s
emergency medical condition once the patient is admitted. Instead, relief for any criticisms
of treatment fall in the area of state medical malpractice law.

                                             9
directly spoken on the issue. Therefore, we apply Chevron deference to the CMS’s

regulation, concluding that the CMS’s interpretation of EMTALA is permissible. See

Torretti v. Main Line Hosps., Inc., 580 F.3d 168, 174 (3d Cir. 2009). 5 The good faith

admission requirement seems to flow logically from the text and the intent of EMTALA

and from our Bryan decision. Bryan makes clear that EMTALA’s obligations end once a

patient is admitted for treatment. The good faith requirement simply clarifies that any

admission must be legitimate and not in name only. While not heretofore an express part

of our Circuit’s concept of admission, the good faith requirement seems at least implicit in

it. Therefore, deferring to the CMS’s regulation, we conclude that while a patient’s

admission for treatment terminates EMTALA’s obligations, the admission must be in good

faith.

         Having adopted the requirement of a good faith admission, we must next decide

what is required to show a lack of good faith in patient admission under EMTALA. The

2003 CMS final rule provides that the standard is high, finding that EMTALA liability may

attach when a hospital ostensibly admits a patient “with no intention of treating the patient,

and then inappropriately transfer[s] or discharg[es] the patient without having met the

stabilization requirement.” 68 F.R. 53222-01, 2003 WL 22074670, at *53245. That

standard is consistent with the approach of the Ninth Circuit. See Bryant v. Adventist Health

System/West, 289 F.3d 1162, 1169 (9th Cir. 2002) (holding liability under EMTALA may


         5
        Even under a lesser standard of deference, the regulation commands an ability to
persuade given the purpose of EMTALA. See Skidmore v. Swift & Co., 323 U.S. 134, 140
(1944).

                                             10
attach if a patient demonstrates that inpatient admission was a ruse to avoid EMTALA’s

requirements). We agree and hold today that a party claiming an admission was not in good

faith must present evidence that the hospital admitted the patient solely to satisfy its

EMTALA standards with no intent to treat the patient once admitted and then immediately

transferred the patient. In other words, the standard requires evidence that the admission

was a subterfuge or a ruse. The standard is not satisfied by simply alleging or showing

deficiencies in treatment following admission.

       Here, Williams fails to point to evidence that creates a genuine issue of material fact

as to this high standard. And our review of the record reveals no evidence that the Hospital

admitted Williams as a subterfuge with no intent to treat him. In fact, the record

demonstrates that Hospital staff provided extensive treatment and surgeries to Williams

right after his arrival on May 3 and for the next eleven days. When Williams arrived,

Hospital staff screened Williams and provided extensive resuscitative and diagnostic

treatment in the form of infusions and scans between 1:30 A.M. and 4:00 A.M. Doctors

then operated on Williams for over six hours trying to treat his condition. For the next ten

days, Hospital staff provided additional treatment to Williams, including multiple

surgeries.

       What’s more, the evidence Williams presented and the arguments he makes on

appeal go to the quality of his treatment, citing complaints about the lack of qualified

medical professionals and the treatment decisions of certain medical staff. More

specifically, Williams contends that certain diagnostic treatment performed by hospital

staff was unnecessary and that, instead, doctors should have started surgery sooner. As

                                             11
noted above, this type of evidence is insufficient as a matter of law to establish a lack of

good faith in patient admission under EMTALA. This evidence and these arguments bear

all the hallmarks of a malpractice claim. To paraphrase a famous saying, if it walks like a

malpractice claim and talks like a malpractice claim, it must be a malpractice claim. But

EMTALA does not generally provide a vehicle for claims that are at their core malpractice

in nature. See 68 F.R. 53222-01, 2003 WL 22074670, at *53244 (“The courts have

generally acknowledged that this limitation on the scope of the stabilization requirement

does not protect hospitals from challenges to the decisions they make about patient care;

only that redress may lie outside EMTALA.”). 6 For those claims, Williams must pursue

recovery under state malpractice law.

       Further, Williams failed to point to any evidence in support of his theory that the

Hospital admitted Williams to improperly hoard him in order to garner his premium

insurance benefits. In fact, this hoarding theory actually undercuts Williams’ argument that

his admission lacked good faith. If there was evidence the Hospital admitted Williams to

hoard him, which we do not see in the record, that would mean that the Hospital admitted

Williams not without the intent to treat him, but with the specific intent to treat him

precisely because Williams had excellent insurance coverage. Such a claim, even if true,




       6
        In certain limited cases, there may be some overlap between an EMTALA claim
and a medical malpractice claim. See Power v. Arlington Hosp. Ass’n, 42 F.3d 851, 858–
59 (4th Cir. 1994) (recognizing a potential for overlap between a failure to screen claim
under EMTALA and a medical malpractice claim).

                                            12
would represent the polar opposite of a bad faith admission, which, once again, is an

admission without the intent to provide treatment and subsequent transfer.

      In conclusion, although Williams has perhaps produced evidence questioning the

Hospital’s treatment of him, he has failed to produce evidence creating a genuine issue of

material fact that his admission to the Hospital lacked good faith. Consequently, because

the Hospital admitted Williams in good faith, it satisfied its obligations under EMTALA.

                                            III.

      For these reasons, the judgment of the district court is

                                                                             AFFIRMED.




                                            13
