Athletic Training Chapter 3- Legal concerns and insurance issues

Legal concerns

rule rather than exception

Liability

being legally responsible for the harm one causes another

The Standard of Reasonable Care

assumes that an individual is neither exceptionally skillful nor extraordinarily cautious but is a person of reasonable and ordinary prudence

Negligence

the failure to use ordinary or reasonable care, care that would normally exercise to avoid injury to themselves or to others under similar circumstances

To establish negligence the one making the complaint must establish 3 things:

a duty of care; conduct of the defendant fell short of that duty of care; resultant damages

Torts

legal wrong committed against the person or property of another

nonfeasance

an act of omission; failure to perform a legal duty

malfeasance

an act of commission; committing an act that is not legally his or hers to perform

Misfeasance

improperly doing something that he or she has the legal right to do

Tort of negligence

negligence is alleged when an individual: does something a reasonable and prudent person would not do; fails to do something that a reasonably prudent person would do under circumstances similar to those shown by the evidence

In a suit of negligence, and individual must prove:

The AT had a duty to exercise reasonable care; the AT breached that duty by failing to use reasonable care; there is a reasonable connection between the failure to use reasonable care and the injury the individual suffered

AT's employed at an institution have a duty to provide athletic training care to ...

individuals at the institution

Sovereign immunity

a legal doctrine, states that neither the gov't nor an individual who is employed by the gov't can be held liable for negligence; level of protection varies by state; AT is not obligated to provide first aid care for an injured person outside his or her scope of employment; Good samaritan law

Good Samaritan Law

Provides limited protection against legal liability to any person who voluntarily chooses to provide first aid

Statues of Limitations

A specific length of time that individuals may sue for damages from negligence; varies by state; generally have between 1-5 years to file suit for negligence; starts from time of negligent act or omission resulting in suit or the time of discovery of injury caused by act.

Assumption of Risk

An athlete assumes the risk of participating in an activity when he or she knows of an understands the dangers of that activity and voluntarily chooses to be exposed to those dangers; can be in the form of a waiver or implied; can be used as defence to negligence suit; subject to varied interpretations; does not excuse those in charge from exercising reasonable care and prudent in the conduct of activities

Waiver

Signed by an athlete or his or her parents or guardian

Implied

From the conduct of an athlete under the circumstances of his or her participation in an activity

Reducing Risk of Litigation

Good personal relationships with athletes parents etc; establish policies and guidelines for operation of AT facility; emergency action plan; know medical history and health statuses; keep records; document efforts to create safe environment; have detailed job description in writing; obtain written consent for providing health care; maintain confidentiality; exercise caution in administering nonprescription meds; use only therapeutic methods one is qualified to use; no hazardous equipment; work cooperatively with coach and physician; do not let injured players participate unless cleared by team physician; tell coaches injured will not be allowed to reenter competition unless psychologically and physically able to; follow orders of physician; purchase professional liability insurance; know limitations of expertise; use common sense;

Product liability

the liability of any or all parties along the chain of manufacture of any product for damaged caused by that product; Can be based on the following (depending on the jurisdiction within which the claim is based): negligence, strict liability, breach of warranty of fitness; there is no federal product liability law; Does not excuse the AT who misuses equipment, only faulty equipment, AT must not alter equipment in any way

General Health Insurance

Covers illness, hospitalization, and emergency care; should make sure all individuals are covered by health insurance

Primary insurance (general)

All expenses are paid for by institution

Secondary insurance (general)

Pays the remaining bills after the personal insurance company ; always includes a deductible;

Accident Insurance

Covers accidents on school grounds while the student is in attendance or accidents that occur in the workplace; designed to take over when general health insurance stops; protects against financial loss from medical and hospital bills; coverage may be limited

Professional liability Insurance

covers claims of negligence of the part of individuals; typically in a civil case; protects against damages that mayrise from the injuries occurring on their property; main concern-whether supervision was reasonable and if unreasonable risk of harm was perceived by the individual who was injured; understand the limits of coverage

Catastrophic insurance

covers medical costs of a catastrophic injury after available funds have been completely diminished; NCAA and NAIA ($25,000), National Federation of State High School Associations - NFSHSA ($10,000); Cost is based on # of sports and # of hazardous sports offered by insitution

Third Party Reimbursement

Primary mechanism of payment for medical services in the US ; the policy holder's insurance company reimburses health care professionals for services performed

HMOs

Health Maintenance Organizations: Provide preventive measures and limit where the individual can receive care; must obtain permission to go to another provider

PPOs

Preferred Provider Organizations: Provide discount health care but also limit where a person can go for treatment of an illness ; pay on a fee for service basis

POS

Point of Service Plan: Combo of the HMO and PPO plans; based on a HMO structure, but allows members to go outside to obtain services; flexibility only with certain conditions and under special circumstances;

EPOs

Exclusive Provider Organizations: Combo of the HMO and PPO plans ; restrictive in the number and types of providers, will not pay out of network

PHOs

Physician Hospital Organizations: Involve a major hospital or hospital chain and its physicians

Third Party Administrators (TPAs)

Used to administer services and to pay claims for self-insured group plans (pseudo insurance companies)

Medicare

Federal health insurance program for the aged and disabled

Medicaid

Health insurance program for people with low incomes and limited resources (federal and state)

Workers Compensation

Mandated by the states; Goal is to return injured workers to the workforce ASAP

Indemnity Plans (most traditional)

Fee for service plan, no restrictions on utilization or cost

Capitation (used by managed care providers)

Members make a standard payment each month

Centers for Medicare and Medicaid Services (CMS) Ruling

2005- CMS made a ruling that stated they would no longer pay for therapy incident to a physicians services unless the provider is a physical therapist, occupational therapist or speech/language therapist. 2009- Athletic Trainers' Equal Access to Medicare Act (bill HR 1137) was intruduced in the US house of Reps. Seeks to ensure that Medicare beneficiaries have better access to health care provided by state licensed or certified ATs

Insurance Billing-Diagnostic Codes

ICD-9

Insurance Billing- Procedural codes

CPT

Filing and insurance claim

most carriers accept a standard form labeled HCFA-1500/HCFA=1450 or UB-92

National Provider Identifier (NPI)

A government issued identification number for individual health care providers and provider organizations; covered health care providers and all health plans must use the NPIs in administration and financial transactions (HIPAA); 10 digit numeric provider