© 2011 McGraw-Hill Higher Education. All rights reserved Chapter 3: Legal Concerns and Insurance...

© 2011 McGraw-Hill Higher Education. All rights reserved

Chapter 3: Legal Concerns and

Insurance Issues


Legal Concerns for the Athletic Trainer

• Lawsuits have become the rule rather than the exception

• Athletic trainers are held accountable for their patient care, what they do and don’t do


Liability:

State of being legally responsible for the harm one causes to another person.An athletic trainer is liable.


Standard of Reasonable Care

• Negligence– failure to use ordinary or reasonable care

•Care that persons would normally do to avoid injury to themselves or others

• Standards of reasonable care–Bring commonsense approach to the situation– Must operate within the appropriate limitations of ones educational background


To Prove Negligence

• Duty to Care: part of official job description

• Breach of duty: conduct fell short

• Damages


Torts: Legal wrongs committed against a

person (liability results)•May emanate from – Nonfeasance

• Fail to perform legal duty (i.e. fail to refer)

– Malfeasance • Performs action that is not his/hers to legally perform (i.e. perform advanced treatment leading to complications)

– Misfeasance• Performs an action incorrectly that the he/she has the legal right to do


Proving Negligence•For a negligence suit to be successful

– Must prove the athletic trainer had a duty to exercise reasonable care– The athletic trainer breached that duty– Establish a connection between the failure to use reasonable care and the injury suffered by the individual


• Individual possessing higher level of training will possess higher level of competence

• Once coach or athletic trainer assumes duty of caring for athlete that person has an obligation to provide appropriate care


Legal Protection

• Sovereign Immunity– Neither the government nor individuals

employed by the government can be held liable for negligence

– May vary state to state

• Good Samaritan Law– Provides limited protection against legal liability

to one that provides care should something go wrong


Statutes of Limitation

• Specific length of time an individual can sue for injury resulting from negligence.

• Varies by state but generally ranges from one to three years

• Clock begins at the time the negligent act results in suit or from the time injury is discovered following negligent act

• Minors have generally have an extension


Assumption of Risk: Individual is made aware of inherent risks involved in sport and voluntarily decides to continue participating

• Expressed in written waiver or implied from conduct of athlete once participation begins

• Can be used as defense against an individual’s negligence suit


Reducing the Risk of

Litigation


Athletic Trainer

• Work to establish good working relationships with athletes, parents, patients, and coworkers

• Establish policies regarding athletic training facility and coverage

• Develop emergency action plan• Become familiar with medical history of

individuals under your care• Maintain adequate records


• Detailed job description• Obtain written consent relative to providing

health care• Maintain confidentiality• Exercise caution with regards to medication

distribution and modality use• Ensure safe equipment and facilities• Develop an understanding with coaches on how

and when injured participants will be cleared for return to play

• Allow injured players to return following physician clearance


• Follow physician’s orders, particularly when dealing with participation of athlete

• Purchase liability insurance• Know scope of practice• Use common sense


Product Liability• Liability of any or all parties involved in

manufactured product for damages caused by product– Includes manufacturer of components,

assemblers, wholesaler, and retail store owner

• Products with inherent defects are subject to liability suits

• May be based on negligence, strict liability or breach of warranty fitness


• Equipment warning labels– Informs individual of possible dangers inherent

with product use– National Operating Committee on Standards for

Athletic Equipment (NOCSAE)• Minimum standards for equipment to ensure safety

• Athletic trainers should not alter equipment– Doing so invalidates the manufacturers warranty– Results in placing liability solely on the athletic trainer


ASSIGNMENT: Lawsuit Scenario

• Read the handout on the scenario

• Get into small groups

• Answer outline

• Discuss


Insurance Considerations

• Medical insurance is a contract between the company and policyholder

• Company agrees to pay portion of medical bills following payment of a deductible


General Health Insurance: Policy that covers illnesses, hospitalization and emergency care

• Sometimes offered through academic institutions for students (athletics)

• Secondary insurance provided through institutions to cover costs above primary insurance coverage

• Schools and universities must ensure that individuals have primary insurance coverage (in place or arranged for)


Accident Insurance

• Low cost plan to cover accident on school grounds or in workplace

• Protects against financial loss from medical and hospital bills

• Provides for additional protection for institution above regular policy

• Will cover costs associated with hospital care, surgery, and catastrophic injuries


Professional Liability Insurance

• Liability insurance covers against claims of negligence on part of individuals

• Because of rise in lawsuits, professionals must be fully protected, particularly in regards to negligence


Catastrophic Insurance

• Catastrophic injuries in athletics are relatively rare, but are staggering to all involved

• Organizations (NCAA, NAIA, NFSHSA) provide additional coverage to deal with lifetime extensive care


Third-Party Reimbursement

• Primary mechanism of payment for medical services in the U.S.

• Policyholder insurance company reimburses health care providers for services rendered

• Number of different options– Pre-arranged systems

• Payment for preventive care– Other systems developed to contain costs


Health Maintenance Organization (HMO)

• Provide preventive measures and dictate where individual can receive care

• Permission must be gained to see someone outside of the plan (except in emergencies)


Preferred Providers Organization (PPO)

• Provide discount health care and also limit where treatment can be obtained

• Must be aware of what facilities are approved for the program in order have cost completely covered

• May include additional types of coverage (physical therapy)

• PPO pay on a fee-for-service basis


Point of Service

• Combination of HMO and PPO

• Based on HMO model but allows for care outside of the plan

• Flexibility is allowed for certain conditions and circumstances


Exclusive Provider Organization

• Combination of HMO and PPO plans

• Restrictive in number and type of providers ( more like HMO)

• Most will not pay anything if you use out of network providers


Physician Hospital Organization

• Involves a major hospital or hospital chain and its physicians

• PHO organization contract directly with employers to provide services and or contracts with managed care organizations


Third Party Administrators

• Used to administer services• Pay claims for self-insured group

plans functioning as a pseudo insurance company

• Perform member services– Enrollment and billing

• Assist with controlling utilization without financial risk


Medicare

• Federal health insurance program for the aged and disabled

• Most people age qualify for benefits• Two parts

– A: Hospital portion – premium free at retirement to beneficiaries

– B: Physician portion – monthly premium charge


Medicaid

• Health insurance program for people with low incomes and limited resources

• Funded via federal government and individual states

• Individual states administer Medicaid– Benefits will vary by state


Workers Compensation

• Laws and benefits for injured workers are mandated by states

• Employer pays premiums • Claims are settled by workers

compensation insurance carriers• Insurance carrier goal – return

worker to work as soon as possible


Indemnity Plan

• Most traditional form of billing for health care

• Fee-for-service plan that allows insured party to seek care without restrictions

• Provider charges patient or third-party payer

• Charges are set on fee schedule


Capitation

• Form of reimbursement where members make standard payment monthly regardless of services rendered

• Managed care plans utilize this practice


Insurance Billing

• Must file claims immediately and correctly• To facilitate, collect insurance information at

the start of the academic year• Letters should be sent home to fully explain the

coverage available and necessary procedures• Standard forms are the norm, but accurate and

thorough completion is critical


Filing an Insurance Claim

• Standard forms are utilized– Must be complete and detailed– More accuracy and thoroughness = quick

return and higher rate of reimbursement

• Billing Codes– Diagnostic code

• Specifies injury/condition that is being treated

– Procedural code


ASSIGNMENT: Insurance Scenario

• Get Scenario Handout

• Read Scenario

• Get in small groups

• Answer questions

• Discuss

© 2011 McGraw-Hill Higher Education. All rights reserved Chapter 3: Legal Concerns and Insurance...

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Transcript of © 2011 McGraw-Hill Higher Education. All rights reserved Chapter 3: Legal Concerns and Insurance...